Hybrid multi-step nucleic acid amplification

ABSTRACT

Improved methods for amplifying target nucleic acid sequences are provided by 1) first amplifying the number of copies of target nucleic acid sequences in a sample by a first nucleic acid amplification method, and then 2) applying a second nucleic amplification method to the amplified sample, or aliquot thereof, further amplifying the number of copies of target sequences. In embodiments, a first nucleic acid amplification method is a thermocycling method, and a second nucleic acid amplification method is an isothermal method.

CROSS-REFERENCE

This application claims priority to U.S. Applications Nos. 62/368,961filed Jul. 29, 2016, 62/368,995 filed Jul. 29, 2016, 62/369,006 filedJul. 29, 2016, 62/369,179 filed Jul. 31, 2016, and 62/368,904 filed Jul.29, 2016. All of the foregoing applications and patents are incorporatedherein by reference in their entirety for all purposes.

The instant application contains a Sequence Listing which has beensubmitted electronically in ASCII format and is hereby incorporated byreference in its entirety. Said ASCII copy, created on Nov. 16, 2017, isnamed 3043_201_SL.txt and is 9,540 bytes in size.

BACKGROUND

While multiple techniques for the amplification of nucleic acids areknown, current techniques suffer from various limitations such as inrelation to the speed, sensitivity, and/or specificity of target nucleicacid amplification. Accordingly, improved nucleic acid amplificationtechniques are needed.

INCORPORATION BY REFERENCE

All publications, patents, and patent applications mentioned in thisspecification are herein incorporated by reference to the same extent asif each individual publication, patent, or patent application wasspecifically and individually indicated to be incorporated by reference.

SUMMARY

Applicant discloses improved methods for amplifying one or more targetnucleic acid sequences in a sample. Target nucleic acids may be DNAsequences, or may be RNA sequences. Improved nucleic acid amplificationmethods disclosed herein comprise utilizing two different nucleic acidamplification methods sequentially. In embodiments, a first nucleicamplification method is applied to a sample, amplifying the number ofcopies of one or more target nucleic acid sequences in the sample;followed by application of a second nucleic amplification method to thesample, or aliquot thereof, further amplifying the number of copies ofone or more target nucleic acid sequences in the sample. In embodiments,any two nucleic amplification methods may be performed sequentially,wherein a first nucleic amplification method is applied to a sample, andthen a second nucleic amplification method is applied to that sample, oran aliquot thereof, after amplification by the first nucleicamplification method. In embodiments, an improved nucleic acidamplification method comprises first utilizing a thermocyclingamplification method, and then utilizing a non-thermocycling (e.g., anisothermal) amplification method, to amplify a target nucleic acidsequence, or to amplify a plurality of target nucleic acid sequences, ina sample. In embodiments, a first nucleic amplification method comprisesa polymerase chain reaction (PCR) amplification method. Suitable PCRmethods include two-step PCR, and include 3-step PCR methods. Inembodiments where the target nucleic acid is RNA, reverse transcriptasePCR (rtPCR) may be used. In embodiments, a second nucleic amplificationmethod comprises an isothermal nucleic acid amplification method asdescribed in International Application No. PCT/US14/30028, filed Mar.15, 2014; in International Application No. PCT/US14/30034, filed Mar.15, 2014; in International Application No. PCT/US14/56151, filed Sep.17, 2014; in International Application No. PCT/US14/30036, filed Mar.15, 2014; or in International Application No. PCT/US15/50811, filed Sep.17, 2015, each of which applications are hereby incorporated byreference herein in their entirety for all purposes.

Accordingly, a method for amplifying a target nucleic acid sequence in asample comprises: amplifying the number of copies of one or more targetnucleic acid sequences in the sample by a first nucleic acidamplification method; and then further amplifying the number of copiesof said one or more target nucleic acid sequences in the sample, or analiquot thereof, by a second nucleic amplification method. Inembodiments, a method for amplifying a target nucleic acid sequence in asample comprises: amplifying the number of copies of one or more targetnucleic acid sequences in the sample by a thermocycling nucleic acidamplification method; and then further amplifying the number of copiesof said one or more target nucleic acid sequences in the sample, or analiquot thereof, by a non-thermocycling (e.g., an isothermal) nucleicamplification method. In embodiments, a method for amplifying a targetnucleic acid sequence in a sample comprises: amplifying the number ofcopies of one or more target nucleic acid sequences in the sample by apolymerase chain reaction (PCR) nucleic acid amplification method; andthen further amplifying the number of copies of said one or more targetnucleic acid sequences in the sample, or an aliquot thereof, by anisothermal nucleic amplification method selected from an isothermalnucleic amplification method as described in International ApplicationNo. PCT/US14/30028, filed Mar. 15, 2014; in International ApplicationNo. PCT/US14/30034, filed Mar. 15, 2014; in International ApplicationNo. PCT/US14/56151, filed Sep. 17, 2014; in International ApplicationNo. PCT/US14/30036, filed Mar. 15, 2014; or in International ApplicationNo. PCT/US15/50811, filed Sep. 17, 2015.

In further embodiments, a method for amplifying a target nucleic acidsequence in a sample comprises: contacting a sample with a primer, orset of primers which hybridize to a target nucleic acid sequence;amplifying the number of copies of said target nucleic acid sequence inthe sample by a first nucleic acid amplification method; and thenfurther amplifying the number of copies of said target nucleic acidsequences in the sample, or an aliquot thereof, by a second nucleicamplification method. Further embodiments include contacting a samplewith a plurality of primers, or a plurality of sets of primers, whichhybridize to a plurality of target nucleic acid sequences; amplifyingthe number of copies of said target nucleic acid sequence in the sampleby a first nucleic acid amplification method; and then furtheramplifying the number of copies of said target nucleic acid sequences inthe sample, or an aliquot thereof, by a second nucleic amplificationmethod.

In further embodiments, an improved nucleic acid amplification methodcomprises first utilizing a non-thermocycling (e.g., an isothermal)amplification method to amplify a target nucleic acid sequence, or toamplify a plurality of target nucleic acid sequences, in a sample, andthen second applying a thermocycling amplification method to theamplified sample, or aliquot thereof, to further amplify a targetnucleic acid sequence, or to amplify a plurality of target nucleic acidsequences, in the sample.

Accordingly, Applicant discloses herein methods, devices, systems,implements (e.g., vessels), and kits for performing nucleic acidamplification. In embodiments, such methods, devices, systems,implements (e.g., vessels), and kits for performing nucleic acidamplification include methods, devices, systems, implements (e.g.,vessels), and kits for amplification of nucleic acids from a sample,such as a clinical sample. In embodiments, a portion (e.g., an aliquot)of a sample may be used to provide a nucleic acid for amplification. Inembodiments, such a sample may be a blood, urine, saliva, or otherclinical sample, or a portion (e.g., an aliquot) of a blood, urine,saliva, or other clinical sample.

Accordingly, in embodiments, Applicant discloses a method for amplifyinga target nucleic acid sequence in a sample, comprising:

first amplifying the number of copies of one or more target nucleic acidsequences in the sample by a first nucleic acid amplification method;and next further amplifying the number of copies of said one or moretarget nucleic acid sequences in the sample, or an aliquot thereof, by asecond nucleic amplification method. In embodiments of such methods,said first nucleic acid amplification method comprises a thermocyclingnucleic acid amplification method. In embodiments of such methods, saidsecond nucleic acid amplification method comprises an isothermal nucleicamplification method. In embodiments of such methods, said first nucleicacid amplification method comprises a thermocycling nucleic acidamplification method, and said second nucleic acid amplification methodcomprises an isothermal nucleic amplification method. In embodiments ofsuch methods, said first nucleic acid amplification method comprises apolymerase chain reaction (PCR) nucleic acid amplification method. Inembodiments of such methods, the nucleic acid amplified by the PCRamplification method comprises DNA. In embodiments of such methods, thenucleic acid amplified by the PCR amplification method comprises RNA. Inembodiments, the nucleic acid may include uracil, and in embodiments mayinclude dideoxyuracil (e.g., may include dideoxyuracil in place of athymine during amplification). In embodiments of such methods, saidsecond nucleic acid amplification method comprises an isothermal nucleicamplification method.

In embodiments of the methods disclosed herein, primers used in theamplification methods are directed to a single target nucleic acidsequence, and its complement. In embodiments of the methods disclosedherein, primers used in the amplification methods are directed to aplurality of target nucleic acid sequences, and complements thereof.

Accordingly, in embodiments, Applicant discloses a method for detectinga first genetic element and a second genetic element on a common nucleicacid molecule, the method comprising:

performing a first nucleic acid amplification reaction using a firstprimer and a second primer, wherein both the first primer and the secondprimer are phosphorylated on the 5′ end of the primer, wherein the firstprimer is complementary to the first genetic element, wherein the secondprimer is complementary to the second genetic element, and wherein afirst reaction product is formed, wherein the first reaction productcontains at least a portion of the first genetic element and at least aportion of the second genetic element, wherein the least a portion ofthe first genetic element and at least a portion of the second geneticelement are separated from each other in the first reaction product by Xnumber of nucleotides;

incubating the first reaction product with a ligase enzyme, to form atleast a first ligation product containing the first reaction product,wherein within the first ligation product a copy of the at least aportion of the first genetic element and a copy of the at least aportion of the second genetic element are separated from each other byless than X number of nucleotides;

performing a second nucleic acid amplification reaction using a thirdprimer and a fourth primer, wherein the third primer is complementary tothe first genetic element, and wherein the fourth primer iscomplementary to the second genetic element, wherein a second reactionproduct is formed; and

detecting the second reaction product.

Accordingly, in embodiments, Applicant discloses a method for amplifyinga polynucleotide template, the method comprising:

A) generating multiple copies of a polynucleotide template in apolymerase chain reaction (PCR) amplification reaction mixture, whereinthe PCR amplification reaction mixture comprises a first PCRamplification reaction primer and a second PCR amplification reactionprimer, wherein in the PCR amplification reaction mixture, the first PCRamplification reaction primer anneals to the polynucleotide template andthe second PCR amplification reaction primer anneals to a polynucleotidewhich is complementary to the polynucleotide template, and wherein inthe PCR amplification reaction mixture, multiple copies of a PCRamplification reaction product are formed, wherein the PCR amplificationreaction product is a double-stranded nucleic acid molecule comprising afirst strand and a second strand, and wherein a first strand of the PCRamplification reaction product is a copy of the polynucleotide template;

B) incubating copies of the polynucleotide template in anon-thermocycling reaction mixture comprising a non-thermocyclingreaction first primer and a non-thermocycling reaction second primer,wherein:

the polynucleotide template comprises a first portion, a second portionand a third portion, wherein the third portion is situated in thepolynucleotide template between the first portion and the secondportion;

the first primer comprises a first region and a second region, whereinthe second region of the first primer is complementary to the firstportion of the polynucleotide template; and

the second primer comprises a first region and a second region, whereinthe second region of the second primer is complementary to a sequence inthe PCR amplification reaction product second strand which iscomplementary to the second portion of the polynucleotide template, thefirst region of the second primer is complementary to the first regionof the first primer, and the first region of the second primer iscomplementary to the third portion of the polynucleotide template.

In embodiments of the methods disclosed herein, the first portion andsecond portion of the polynucleotide template are each between 6 and 30nucleotides in length. In embodiments of such methods, the third portionof the polynucleotide template is between 4 and 14 nucleotides inlength. In embodiments of the methods disclosed herein, the number ofcopies of the polynucleotide template in the non-thermocycling reactionmixture is increased at least 10-fold within 60 minutes of initiation ofthe method. In embodiments of the methods disclosed herein, a concatemerstrand comprising at least three copies of the polynucleotide templateis generated during the incubation of the non-thermocycling reactionmixture.

Applicants further disclose herein a vessel, and vessels, comprisingtherein any one or more components of a reaction mixture providedherein. Applicants further disclose herein a kit, and kits, comprisingtherein any one or more components of a reaction mixture providedherein.

The assays and methods disclosed herein may be performed on a device, oron a system, for processing a sample. The assays and methods disclosedherein can be readily incorporated into and used in an automated assaydevice, and in an automated assay system. For example, systems asdisclosed herein may include a communication assembly for transmittingor receiving a protocol based on the analyte to be detected (e.g., oneor more nucleic acid markers indicative of a virus, a bacterium, orother target) or based on other analytes to be detected by the device orsystem. In embodiments, an assay protocol may be changed based onoptimal scheduling of a plurality of assays to be performed by a device,or may be changed based on results previously obtained from a samplefrom a subject, or based on results previously obtained from a differentsample from the subject. In embodiments, a communication assembly maycomprise a channel for communicating information from said device to acomputer, said wherein said channel is selected from a computer network,a telephone network, a metal communication link, an opticalcommunication link, and a wireless communication link. In embodiments,systems as disclosed herein may transmit signals to a central location,or to an end user, and may include a communication assembly fortransmitting such signals. Systems as disclosed herein may be configuredfor updating a protocol as needed or on a regular basis.

Devices and systems configured to measure nucleic acid markers (e.g.,which may be indicative of a virus, a bacterium, or other target) in asample of blood according to a method disclosed herein may be configuredto determine from analysis of a portion of a sample (e.g., a sample ofblood, urine, sputum, tears, or other sample) that comprises a volume ofno more than about 1000 μL, or no more than about 500 μL, no more thanabout 250 μL, or no more than about 150 μL, or no more than about 100μL, or no more than about 50 μL, or, in embodiments, wherein the volumeof the sample comprises no more than about 25 μL, or comprises no morethan about 10 μL, or wherein said sample of blood comprises less thanabout 10 μL. Such devices may be configured to measure target levels, orto detect the presence or absence of a target in a sample, in less thanabout one hour, or, in embodiments, in less than about 40 minutes, or inless than about 30 minutes.

Devices disclosed herein may be configured to perform an assay for themeasurement of a target nucleic acid and also to perform an assay forthe measurement of another analyte in the blood sample. Devicesdisclosed herein may be configured to perform an assay for themeasurement of a target nucleic acid molecule, and also to perform anassay comprising the measurement of a morphological characteristic of ablood cell in the blood sample. Devices disclosed herein may beconfigured to perform an assay for the measurement of a target nucleicacid molecule and also to perform an assay comprising the measurement ofanother blood analyte, e.g., a vitamin, a hormone, a drug or metaboliteof a drug, or other analyte. Such devices may be configured wherein theassays, or the order of performance of assays, that are performed bysaid device may be altered by communication with another device.

Applicants also disclose systems comprising a device as disclosedherein. In embodiments, the system comprises a device that is configuredto perform an assay for the measurement of a target nucleic acidmolecule and also to perform an assay for the measurement of anotheranalyte in the sample. In embodiments, the system comprises a devicethat is configured to perform an assay for the measurement of a targetnucleic acid molecule and also to perform an assay for the measurementof a morphological characteristic of a cell in the sample. Inembodiments of such a system, assays, or the order of performance ofassays, that are performed by said device may be altered bycommunication with another device.

Methods, systems, devices, kits, and compositions disclosed hereinprovide rapid assays which require only small amounts of sample, such asonly small amounts of blood, urine, tears, sweat, tissue, or othersample. Device and systems disclosed herein are configured to performsuch rapid assays which require only small amounts of sample, such assamples or sample portions having volumes of less than about 250 μL, orless than about 200 μL, or less than about 150 μL, or less than about100 μL. Accordingly, the methods, compositions, devices, and systemsprovide rapid tests, which require only small biological samples, andthus provide advantages over other methods, compositions, assays,devices, and systems.

Applicant discloses herein compositions comprising one or more ofreagents, including primers, nucleotides, dyes, buffers, and otherreagents useful for methods disclosed herein. Applicant discloses hereinvessels for use in assay devices, assay systems, including automatedassay devices, automated assay systems (which may also be termed sampleanalysis devices and systems, and automated sample analysis devices andsystems) useful for methods disclosed herein. Applicant discloses hereinimplements, tools, and disposables for use in assay devices, assaysystems, including automated assay devices and automated assay systemsuseful for methods disclosed herein. Applicant discloses herein vesselscontaining one or more of reagents, including primers, nucleotides,dyes, and other reagents useful for methods disclosed herein. Applicantdiscloses herein kits including compositions comprising one or more ofreagents, including primers, nucleotides, dyes, buffers, and otherreagents useful for methods disclosed herein; kits including vessels foruse in assay devices, assay systems, including automated assay devicesand automated assay systems useful for methods disclosed herein; andkits including compositions and vessels for use in assay devices, assaysystems, including automated assay devices and automated assay systemsuseful for methods disclosed herein.

Methods, systems, devices, kits, and compositions disclosed hereinprovide advantages including greater sensitivity than other methods.Methods, systems, devices, kits, and compositions disclosed hereinprovide advantages including improved ability to multiplex two or moreamplification reactions in a single nucleic amplification device orsystem (which may be or include, e.g., automated assay devices,automated assay systems, which may also be termed sample analysisdevices and systems, and automated sample analysis devices and systems).Methods, systems, devices, kits, and compositions disclosed hereinprovide advantages including improved ability to amplify two, three, ormore target nucleic acids in a single vessel in a first nucleic acidamplification step, and follow up with steps directed to individualtarget nucleic acids in multiple individual vessels in multiple secondnucleic acid amplification steps. Methods, systems, devices, kits, andcompositions disclosed herein provide advantages including improvedability to amplify, detect, or identify, and combinations thereof,single nucleotide polymorphisms (SNPs) in target nucleic acids. Methods,systems, devices, kits, and compositions disclosed herein provideadvantages including improved ability to perform PCR without use of dyesin a first nucleic acid amplification step, and to follow up with asecond nucleic acid amplification step comprising the use of dyes, fordetecting target nucleic acids pursuant to a second nucleic acidamplification step; for example, such methods systems, devices, kits,and compositions may be useful for detection of SNPs.

Methods, systems, devices, kits, and compositions disclosed hereinprovide advantages including the ability to utilize samples with lesspre-processing than might otherwise be required. Methods, systems,devices, kits, and compositions disclosed herein provide advantagesincluding the ability to dilute samples to a greater amount of dilutionthan might otherwise be required. Methods, systems, devices, kits, andcompositions disclosed herein provide advantages including reducingsusceptibility to contamination by humans (e.g., operator) other thanthe subject than might otherwise occur. Methods, systems, devices, kits,and compositions disclosed herein provide advantages including theability to apply these techniques to the analysis of nasal swabs, whereother methods might require nasopharyngeal swabs.

Other goals and advantages of the invention will be further appreciatedand understood when considered in conjunction with the followingdescription and accompanying drawings. While the following descriptionmay contain specific details describing particular embodiments of theinvention, these should not be construed as limitations to the scope ofthe invention but rather as exemplifications of possible embodiments.For each aspect of the invention, many changes and modifications can bemade within the scope of the invention without departing from the spiritthereof.

BRIEF DESCRIPTION OF THE DRAWINGS

In the drawings,

FIG. 1 shows exemplary results according to a method provided herein.

FIG. 2 shows exemplary results according to a method provided herein.

FIG. 3 shows exemplary results according to a method provided herein.

FIG. 4 shows exemplary results according to a method provided herein.

FIG. 5 shows exemplary results according to a method provided herein.

FIG. 6 depicts exemplary primer sequences which may be used with amethod provided herein. Figure discloses SEQ ID NOS 22-31, respectively,in order of appearance.

FIG. 7 is a general schematic of method provided herein.

FIG. 8 are exemplary primer sequences which may be used with a methodprovided herein. Figure discloses SEQ ID NOS 32-33, respectively, inorder of appearance.

FIG. 9 shows results from a method provided herein.

FIG. 10 shows primer sequences used for a method provided herein. Figurediscloses SEQ ID NOS 34-39, respectively, in order of appearance.

FIG. 11A shows a histogram plot for cut-off determination for ZNAT.

FIG. 11B shows a Table for ZNAT results interpretation.

FIG. 12 provides a standard curve showing the quantification of threeZIKV lysates using qRT-PCR to convert plaque-forming units (PFU) andhalf-maximal tissue culture infective dose (TCID₅₀) to genomic copiesfor three different ZIKV lysates.

FIG. 13 shows results of analytical sensitivity determinations of ZNAT.

FIG. 14 provides a table showing the results of in silico analyses ofZNAT primers against sequenced Zika virus strains.

FIG. 15 shows, in Table form, the results of reactivity/inclusivityanalysis of ZNAT in serum samples.

FIG. 16 provides a table showing in silico analysis of Zika preliminaryamplification and isothermal primers against prevalent diseases withZika-like onset symptoms.

FIG. 17 provides a table showing the results of in silico mismatchanalyses of ZNAT primers against potentially cross-reacting organisms.

FIG. 18 provides a table showing cross-reactivity and the results ofinterfering substances analyses of ZNAT in serum.

FIG. 19 shows a table listing the results of ZNAT tests against possibleinterfering substances in serum.

FIG. 20 provides a table showing the results of analyses of run-to-runcontamination of ZNAT in serum.

FIG. 21 provides a table showing the results of concordance studiesusing ZNAT. Concordance studies results for SPU, CDC RT-PCR, and altonaRealStar® assays. Positive and negative percent agreement (PPA and NPA,respectively) values were determined from results that were in agreementbetween the ZNAT assay run using the SPU and the combined CDC RT-PCR andaltona assays for venous serum samples and capillary whole bloodsamples.

FIG. 22 shows a schematic illustration and a perspective image of anucleic acid amplification (NAA) detector and thermocycler module asdisclosed herein, and includes a schematic illustration of across-section of a photodetection system for detecting fluorescencegenerated by nucleic acid amplification, and further includes (as aninset) an idealized illustration of a plot of fluorescence generatedover time (typically as numbers of cycles) by such amplification.

FIG. 23A shows a listing of exemplary steps of methodology for a NAAZika Assay as disclosed herein.

FIG. 23B shows a listing of performance characteristics of a NAA ZikaAssay as disclosed herein, using venous serum samples.

FIG. 24 shows a listing of analytical sensitivity (limit of detection(LoD)) of a NAA Zika Assay as disclosed herein.

FIG. 25 shows a listing of analytical specificity of a NAA Zika Assay asdisclosed herein.

FIG. 26 shows a further listing of analytical specificity of a NAA ZikaAssay as disclosed herein.

FIG. 27A shows a listing of inclusivity of a NAA Zika Assay as disclosedherein.

FIG. 27B shows a listing of data demonstrating no significant carry-overbetween different samples when analyzed using automated sample analysisdevices and the NAA Zika Assay as disclosed herein.

FIG. 28 shows a clinical study overview of a NAA Zika Assay as disclosedherein.

FIG. 29 shows a comparison (as percent agreement) of a NAA Zika Assay asdisclosed herein with CDC RT-PCR with confirmation by altona RealStar®.

FIG. 30 lists some descriptive characteristics of a clinical study usingthe NAA Zika Assay nucleic acid amplification methods disclosed herein.

FIG. 31 provides a table listing data demonstrating that the results ofa clinical study using the NAA Zika Assay nucleic acid amplificationmethods disclosed herein are consistent with results of comparativeassays.

It is noted that the drawings and elements therein are not necessarilydrawn to shape or scale. For example, the shape or scale of elements ofthe drawings may be simplified or modified for ease or clarity ofpresentation. It should further be understood that the drawings andelements therein are for exemplary illustrative purposes only, and notbe construed as limiting in any way.

DETAILED DESCRIPTION

This application hereby incorporates by reference for all purposes andin their entirety the following patent applications: U.S. ProvisionalPatent Application No. 62/051,912, filed Sep. 17, 2014; U.S. ProvisionalPatent Application No. 62/051,945, filed Sep. 17, 2014; U.S. ProvisionalPatent Application No. 62/068,603, filed Oct. 24, 2014; U.S. ProvisionalPatent Application No. 62/068,605, filed Oct. 24, 2014; U.S. ProvisionalPatent Application No. 62/151,358, filed Apr. 22, 2015; U.S. ProvisionalPatent Application No. 61/908,027, filed Nov. 22, 2013; U.S. ProvisionalPatent Application No. 62/001,050, filed May 20, 2014; and U.S.Provisional Patent Application No. 61/800,606, filed Mar. 15, 2013; U.S.Non-Provisional patent application Ser. No. 14/214,850, filed Mar. 15,2014; International Patent Application No. PCT/US14/30034, filed Mar.15, 2014; International Patent Application No. PCT/US14/56151, filedSep. 17, 2014; International Application No. PCT/US15/50811, filed Sep.17, 2015; International Application No. PCT/US15/50822, filed Sep. 17,2015; and U.S. Non-Provisional patent application Ser. No. 15/087,840,filed Mar. 31, 2016.

Provided herein are devices, systems and methods for amplification ofnucleic acids. Various features described herein may be applied to anyof the particular embodiments set forth below or for any other typessystems for or involving nucleic acid amplification. Systems and methodsdescribed herein may be applied as a standalone system or method, or aspart of an integrated system or method. It shall be understood thatdifferent aspects of the disclosed systems and methods can beappreciated individually, collectively, or in combination with eachother.

In embodiments, a method provided herein may be performed as follows. Apolynucleotide template may be amplified in a first amplificationreaction, wherein the first amplification reaction is a thermocyclingnucleic acid amplification reaction (e.g., a polymerase chain reaction(PCR)). In the first amplification reaction, a nucleic acidamplification reaction product may be generated (e.g., a PCRamplification reaction product may be generated). Amplification reactionproduct generated by the first amplification reaction may then beamplified in a second amplification reaction, wherein the secondamplification reaction is a non-thermocycling nucleic acid amplificationreaction (e.g., an isothermal nucleic acid amplification reaction).

In embodiments, a method provided herein may be performed as follows. Apolynucleotide template may be amplified in a first amplificationreaction, wherein the first amplification reaction is a polymerase chainreaction (PCR) reaction. In the first amplification reaction, a PCRamplification reaction product may be generated. The PCR amplificationreaction product may be a double-stranded nucleic acid moleculecomprising a first strand and a second strand, and wherein a firststrand of the PCR amplification reaction product is a copy of thepolynucleotide template. Next, the PCR reaction product (which comprisesa copy of the polynucleotide template) may be used as a template in anon-thermocycling amplification reaction as provided in PCT/US14/56151,in order to generate a non-thermocycling reaction product as describedin PCT/US14/56151. Such non-thermocycling reaction products may includeconcatemers. In embodiments of this method involving a PCR amplificationreaction followed by a non-thermocycling amplification reaction, onlythe non-thermocycling reaction products are detected (not the PCRreaction products). In embodiments, the non-thermocycling reactionproducts are detected in real-time as they are formed. In embodiments, amethod of PCT/US14/56151 may involve a first primer and a second primer.In embodiments, the first primer of a method of PCT/US14/56151 containsa first region and a second region, wherein the first region comprises a5′ end of the primer, the second region comprises a 3′ end of theprimer, and the second region is complementary to a least a portion of afirst strand of a double-stranded nucleic acid template (i.e. adouble-stranded nucleic acid molecule, such as a PCR amplificationreaction product). In embodiments, the second primer of a method ofPCT/US14/56151 contains a first region and a second region, wherein thefirst region comprises a 5′ end of the primer and is complementary tothe first region of the first primer, the second region comprises a 3′end of the primer, and wherein the second region is complementary to aleast a portion of a second strand of the double-stranded nucleic acidtemplate. In embodiments, the second region of a first primer of amethod of PCT/US14/56151 may anneal to a first strand of a PCRamplification reaction product in methods herein in the same way as afirst PCR amplification reaction primer anneals to a polynucleotidetemplate strand in PCR amplification reactions provided herein, and thesecond region of a second primer of a method of PCT/US14/56151 mayanneal to a second strand of a PCR amplification reaction product asprovided in methods herein in the same way as a second PCR amplificationreaction primer anneals to a polynucleotide which is complementary tothe polynucleotide template in PCR amplification reaction methodsprovided herein.

In further, alternative embodiments, a method provided herein may beperformed as follows. A polynucleotide template may be amplified in afirst amplification reaction, wherein the first amplification reactionis a non-thermocycling nucleic acid amplification reaction (e.g., anisothermal nucleic acid amplification reaction). In the firstamplification reaction, a nucleic acid amplification reaction productmay be generated. Amplification reaction product generated by the firstamplification reaction may then be amplified in a second amplificationreaction, wherein the second amplification reaction is a thermocyclingnucleic acid amplification reaction (e.g., a PCR reaction).

The methods disclosed herein may be performed by assay devices and assaysystems, including automated assay devices and automated assay systems(which may also be termed sample analysis devices and systems, andautomated sample analysis devices and systems).

Definitions

As used herein, a “polynucleotide” refers to a polymeric chaincontaining two or more nucleotides. “Polynucleotides” includes primers,oligonucleotides, nucleic acid strands, etc. A polynucleotide maycontain standard or non-standard nucleotides. Typically, apolynucleotide contains a 5′ phosphate at one terminus (“5′ terminus”)and a 3′ hydroxyl group at the other terminus (“3′ terminus) of thechain. The most 5′ nucleotide of a polynucleotide may be referred toherein as the “5′ terminal nucleotide” of the polynucleotide. The most3′ nucleotide of a polynucleotide may be referred to herein as the “3′terminal nucleotide” of the polynucleotide.

The term “downstream” as used herein in the context of a polynucleotidecontaining a 5′ terminal nucleotide and a 3′ terminal nucleotide refersto a position in the polynucleotide which is closer to the 3′ terminalnucleotide than a reference position in the polynucleotide. For example,in a primer having the sequence: 5′ ATAAGC 3′, the “G” is downstreamfrom the “T” and all of the “A”s.

The term “upstream” as used herein in the context of a polynucleotidecontaining a 5′ terminal nucleotide and a 3′ terminal nucleotide, refersto a position in the polynucleotide which is closer to the 5′ terminalnucleotide than a reference position in the polynucleotide. For example,in a primer having the sequence: 5′ ATAAGC 3′, the “T” is upstream fromthe “G”, the “C”, and the two “A”s closest to the “G”.

As used herein, “nucleic acid” includes both deoxyribonucleic acid (DNA)and ribonucleic acid (RNA) molecules, including DNA and RNA containingnon-standard nucleotides. A “nucleic acid” contains at least onepolynucleotide (a “nucleic acid strand”). A “nucleic acid” may besingle-stranded or double-stranded. Acronyms and abbreviations relatedto nucleic acids as used herein have their standard meanings (e.g.,“mRNA” refers to messenger RNA, “ssDNA” refers to single-stranded DNA,“dsDNA” refers to double-stranded DNA, etc.).

As used herein “cDNA” refers to DNA molecules (“complementary DNA”)produced by reverse transcription of an RNA molecule. Such reversetranscription produces a DNA molecule having a nucleotide sequence thatis the same as the nucleotide sequence of that RNA molecule, with theexception that where the RNA molecule has a uracil moiety (U) the DNAmolecule has instead a thymine (T). A cDNA produced by reversetranscription of an RNA molecule is complementary to the complement ofthat RNA molecule.

The term “primer” as used herein refers to a polynucleotide, whetheroccurring naturally as in a purified restriction digest or producedsynthetically, which is capable of acting as a point of initiation ofsynthesis when placed under conditions in which synthesis of a primerextension product which is complementary to a nucleic acid strand isinduced, i.e., in the presence of nucleotides and an inducing agent suchas DNA polymerase and at a suitable temperature and pH. The primer ispreferably single stranded for maximum efficiency in amplification, butmay alternatively be double stranded. If double stranded, the primer isfirst treated to separate its strands before being used to prepareextension products. Preferably, the primer is apoly-deoxyribonucleotide. The primer must be sufficiently long to primethe synthesis of extension products in the presence of the inducingagent. The exact lengths of the primers will depend on many factors,including temperature, source of primer and use of the method. Forexample, for diagnostics applications, depending on the complexity ofthe target sequence, the polynucleotide primer typically contains about10-30 or more nucleotides, or about 15-25 or more nucleotides, althoughit may contain fewer nucleotides. For other applications, thepolynucleotide primer is typically shorter, e.g., 7-15 nucleotides. Suchshort primer molecules generally require cooler temperatures to formsufficiently stable hybrid complexes with template.

As used herein, when a first polynucleotide is described as “annealed”,“annealing” or the like to a second polynucleotide, the entirety of thefirst polynucleotide or any portion thereof may anneal to the secondpolynucleotide, and vice versa.

The “Tm” indicates the annealing temperature for a particular primerset; a primer set may have a different Tm than other primer sets, or mayhave the same Tm as another primer set. In many cases, Tm is typicallybetween about 45° C. to about 80° C., or between about 50° C. to about75° C.

As used herein, “reverse transcriptase” (RT) refers to an enzyme whichcan be used to produce a DNA molecule that is complementary to a RNAmolecule. The act of producing such a DNA molecule from an RNA templateis termed “reverse transcription”. Where a target nucleic acid is a RNAmolecule, and DNA is desired (e.g., for use with PCR amplificationmethods), a cDNA molecule corresponding to the target RNA may begenerated by reverse transcription.

As used herein, a “concatemer” refers to a nucleic acid molecule whichcontains within it two or more copies of a particular nucleic acid,wherein the copies are linked in series. Within the concatemer, thecopies of the particular nucleic acid may be linked directly to eachother, or they may be indirectly linked (e.g. there may be nucleotidesbetween the copies of the particular nucleic acid). In an example, theparticular nucleic acid may be that of a double-stranded nucleic acidtemplate, such that a concatemer may contain two or more copies of thedouble-stranded nucleic acid template. In another example, theparticular nucleic acid may be that of a polynucleotide template, suchthat a concatemer may contain two or more copies of the polynucleotidetemplate.

As used herein, a “target” nucleic acid or molecule refers to a nucleicacid of interest. A target nucleic acid/molecule may be of any type,including single-stranded or double stranded DNA or RNA (e.g. mRNA).

As used herein, “complementary” sequences refer to two nucleotidesequences which, when aligned anti-parallel to each other, containmultiple individual nucleotide bases which can pair with each otheraccording to standard base-pairing rules (e.g. A-T, G-C, or A-U), suchthat molecules containing the sequences can specifically anneal to eachother. It is not necessary for every nucleotide base in two sequences tobe capable of pairing with each other for the sequences to be considered“complementary”. Sequences may be considered complementary, for example,if at least 30%, 40%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%,98%, 99%, or 100% of the nucleotide bases in two sequences can pair witheach other when the sequences are optimally aligned for complementation.In addition, sequences may still be considered “complementary” when thetotal lengths of the two sequences are significantly different from eachother. For example, a primer of 15 nucleotides may be considered“complementary” to a longer polynucleotide containing hundreds ofnucleotides if multiple individual nucleotide bases of the primer canpair with nucleotide bases in the longer polynucleotide when the primeris aligned anti-parallel to a particular region of the longerpolynucleotide. Additionally, “complementary” sequences may contain oneor more nucleotide analogs or nucleobase analogs. As used herein,“perfectly complementary” or “perfect complementation” or the likerefers two sequences which are 100% complementary to each other (i.e.where there are no mis-matches between the nucleotides of the sequenceswhen the sequences are paired for maximum complementation).

“Identical” or “identity,” as used herein in the context of two or morepolypeptide or polynucleotide sequences, can mean that the sequenceshave a specified percentage of residues that are the same over aspecified region. The percentage can be calculated by optimally aligningthe two sequences, comparing the two sequences over the specifiedregion, determining the number of positions at which the identicalresidue occurs in both sequences to yield the number of matchedpositions, dividing the number of matched positions by the total numberof positions in the specified region, and multiplying the result by 100to yield the percentage of sequence identity. In cases where the twosequences are of different lengths or the alignment produces one or morestaggered ends and the specified region of comparison includes only asingle sequence, the residues of the single sequence are included in thedenominator but not the numerator of the calculation.

“Homology” or “homologous” as used herein in the context of two or morepolypeptide or polynucleotide sequences, can mean that the sequenceshave a specified percentage of residues that are either i) the same, orii) conservative substitutions of the same residue, over a specifiedregion. Conservative substitutions include substitutions of one aminoacid by an amino acid of the same group, and include substitutions ofone amino acid by an amino acid as an exemplary or as a preferredsubstitution as known in the art. In determining homology of twosequences, identical residues and homologous residues are given equalweight. The percentage can be calculated by optimally aligning the twosequences, comparing the two sequences over the specified region,determining the number of positions at which either identical orhomologous residues occur in both sequences to yield the number ofmatched positions, dividing the number of matched positions by the totalnumber of positions in the specified region, and multiplying the resultby 100 to yield the percentage of sequence homology. In cases where thetwo sequences are of different lengths or the alignment produces one ormore staggered ends and the specified region of comparison includes onlya single sequence, the residues of the single sequence are included inthe denominator but not the numerator of the calculation.

As used herein, in the context of two or more polymeric molecules (e.g.nucleic acids, proteins), “corresponds to”, “corresponding to”, and thelike refers to polymeric molecules or portions thereof which have thesame or similar sequence of component elements (e.g. nucleotides, aminoacids). For example, if a first nucleic acid is described as containinga region which “corresponds to” the sequence of a second nucleic acid,the relevant region of the first nucleic acid has a nucleotide sequencewhich is the same or similar to the sequence of the second nucleic acid.

As used herein, the term “isolated” as applied to proteins, nucleicacids, or other biomolecules refers to a molecule that has been purifiedor separated from a component of its naturally-occurring environment(e.g. a protein purified from a cell in which it was naturallyproduced). An “isolated” molecule may be in contact with other molecules(for example, as part of a reaction mixture). As used herein, “isolated”molecules also include recombinantly-produced proteins or nucleic acidswhich have an amino acid or nucleotide sequence which occurs naturally.“Isolated” nucleic acids include polypeptide-encoding nucleic acidmolecules contained in cells that ordinarily express the polypeptidewhere, for example, the nucleic acid molecule is at a chromosomallocation different from that of natural cells. In some embodiments,“isolated” polypeptides are purified to at least 50%, 60%, 70%, 80%,90%, 95%, 98%, or 100% homogeneity as evidenced by SDS-PAGE of thepolypeptides followed by Coomassie blue, silver, or other proteinstaining method.

As used herein, a nucleic acid molecule which is described as containingthe “sequence” of a template or other nucleic acid may also beconsidered to contain the template or other nucleic acid itself (e.g. amolecule which is described as containing the sequence of a template mayalso be described as containing the template), unless the contextclearly dictates otherwise.

As used herein, when a first polynucleotide is described as “annealed”,“annealing” or the like to a second polynucleotide, the entirety of thefirst polynucleotide or any portion thereof may anneal to the secondpolynucleotide, and vice versa.

As used herein, a reference to “treating” a given object to a conditionor other object or the like refers to directly or indirectly exposingthe given object to the recited condition or other object. Thus, while a“treating” step may involve a distinct related action (e.g. adding anenzyme to a vessel, shaking a vessel, etc.), not every “treating” steprequires a distinct related action. For example, a reaction involvingone or more reagents can be set up in a vessel, and once the reactionhas been initiated, multiple events or steps may occur in the vesselwithout further human or mechanical intervention with the contents ofthe vessel. One or more of these multiple events or steps in the vesselmay be described as “treating” an object in the vessel, even if noseparate intervention with the contents of the vessel occurs after theinitiation of the reaction.

As used herein, the term “Zika” refers to Zika virus, and the acronym“ZIKV” also refers to Zika virus. ZIKV is a member of the Flavivirusgenus of viruses (family Flaviviridae). Other members of the genusinclude dengue virus (DENV), West Nile Virus (WNV), Japaneseencephalitis virus (JEV), yellow fever virus (YFV), and tick-borneencephalitic virus (TBEV). Flaviviruses have a single-strand,positive-sense RNA genome that serves both as a genome and messengerRNA. The RNA genome is translated into a single polyprotein that isproteolytically cleaved into three structural proteins (capsid, prM, andenvelope) and non-structural proteins NS1 to NS5. The virion contains anucleocapsid composed of the capsid protein (C) and the RNA genome,surrounded by an icosahedral shell comprising both the envelope (E)glycoprotein and membrane (M) protein or the precursor membrane (prM)protein anchored in a lipid membrane.

A composition may include a buffer. Buffers include, without limitation,phosphate, citrate, ammonium, acetate, carbonate,tris(hydroxymethyl)aminomethane (TRIS), 3-(N-morpholino) propanesuifonicacid (MOPS), 3-morpholino-2-hydroxypropanesulfonic acid (MOPSO),2-(N-morpholino)ethanesulfonic acid (MES), N-(2-Acetamido)-iminodiaceticacid (ADA), piperazine-N,N′-bis(2-ethanesulfonic acid) (PIPES),N-(2-Acetamido)-2-aminoethanesulfonic acid (ACES), cholamine chloride,N,N-Bis(2-hydroxyethyl)-2-aminoethanesulfonic acid (BES),2-[[1,3-dihydroxy-2-(hydroxymethyl)propan-2-yl]amino]ethanesulfonic acid(TES), 4-(2-hydroxyethyl)-1-piperazine ethanesulfonic acid (HEPES),acetamidoglycine, tricine(N-(2-Hydroxy-1,1-bis(hydroxymethyl)ethyl)glycine), glycinamide, andbicine (2-(Bis(2-hydroxyethyl)amino)acetic acid) buffers. Buffersinclude other organic acid buffers in addition to the phosphate,citrate, ammonium, acetate, and carbonate buffers explicitly mentionedherein.

An article of manufacture may comprise a container; and a compositioncontained within the container, wherein the composition comprises anucleic acid molecule (such as, e.g., a primer directed to a targetrelated to ZIKV). An article of manufacture may comprise a container;and a composition contained within the container, wherein thecomposition comprises a nucleic acid molecule (such as, e.g., a primerdirected to a target related to ZIKV). An article of manufacture maycomprise a container; and a composition contained within the container,wherein the composition comprises a nucleic acid molecule (such as,e.g., a primer directed to a target related to ZIKV). The containers maybe formed from a variety of materials such as glass or plastic, and mayhave a sterile access port (for example the container may be anintravenous solution bag or a vial having a stopper pierceable by ahypodermic injection needle). The article of manufacture may furthercomprise a label or package insert on or associated with the containerindicating that the composition may be used to detect the presence of anucleic acid molecule (such as, e.g., a primer directed to a targetrelated to ZIKV) in a sample.

Hybrid Nucleic Acid Amplification Methods

In embodiments, provided herein is method for amplification of a targetnucleic acid, wherein the method includes at least two different nucleicacid amplification processes. In embodiments, a target nucleic acid maybe first be amplified by a first nucleic acid amplification method whichinvolves thermocycling, and then some or all of the target nucleic acidamplified in the thermocycling reaction may then be used for a secondnucleic acid amplification reaction, wherein the second nucleic acidamplification reaction is an isothermal amplification reaction. Forexample, a target nucleic acid may be first amplified in a polymerasechain reaction (“PCR”) amplification reaction (described, for example,in U.S. Pat. No. 4,683,202). PCR amplification methods are thermocyclingamplification methods.

Then, following amplification by a PCR method, some or all of theamplified target nucleic acid from the PCR reaction may be used in anisothermal nucleic acid amplification reaction, such as is described in,for example, any of International Application No. PCT/US14/30028, filedMar. 15, 2014, International Application No. PCT/US14/30034, filed Mar.15, 2014, International Application No. PCT/US14/56151, filed Sep. 17,2014, or International Application No. PCT/US14/30036, filed Mar. 15,2014, are each herein incorporated by reference in their entirety forall purposes. For brevity hereafter, the isothermal nucleic acidamplification methods described in PCT/US14/30028, in PCT/US14/30034, inPCT/US14/56151, and in PCT/US14/30036 are collectively termed “NAA”methods.

The present methods improve (i.e., lower) the limit of detection (LOD)of nucleic acid amplification assays. That is, the presence of smallernumbers of target nucleic acid sequences in a sample can be detectedwhen pre-amplification by thermal-cycling methods are applied to thesample, and then isothermal nucleic acid amplification methods areapplied, as compared to when isothermal methods are applied to a samplewithout such pre-amplification. As few as 1 copy per microliter oftarget nucleic acid has been detected in samples using PCR followed byNAA methods.

PCR Methods

Polymerase chain reaction (“PCR”) methods (see, e.g. U.S. Pat. No.4,683,202) are popular methods for the amplification of nucleic acids.PCR methods are in vitro methods that can be used to amplify specificpolynucleotide sequences, including genomic DNA, single-stranded cDNA,and mRNA among others. As described in U.S. Pat. Nos. 4,683,202,4,683,195, and 4,800,159 (hereby incorporated herein by reference), PCRtypically comprises treating separate complementary strands of a targetnucleic acid with two polynucleotide primers to form complementaryprimer extension products on both strands that act as templates forsynthesizing copies of the desired nucleic acid sequences. By repeatingthe separation and synthesis steps in an automated system, essentiallyexponential duplication of the target sequences can be achieved.

To successfully perform a PCR reaction, the reaction must be performedat multiple different temperatures. This requires hardware or othermechanisms for repeatedly changing the temperature of the PCR reaction.In embodiments where the target nucleic acid is RNA, reversetranscription PCR (rtPCR) may be used.

As used herein, PCR refers to any of the nucleic acid amplificationmethods in which a target nucleic acid (typically a double-strandeddeoxyribonucleic acid) is exposed to a thermostable DNA polymeraseduring multiple thermal cycles, and in which multiple copies of thetarget nucleic acid (typically including copies of nucleic acidsequences disposed between a first target region on one strand of adouble-stranded target nucleic acid and a second target region on thecomplementary strand of a double-stranded target nucleic acid) areproduced, amplifying the target nucleic acid. Thermal cycles typicallyinclude low temperature portions (typically at temperatures betweenabout 40° C. and about 59° C., or between about 45° C. and about 55°C.), intermediate temperature portions (typically at temperaturesbetween about 60° C. and about 74° C.), and higher temperature portions(typically at temperatures between about 75° C. and about 99° C., orbetween about 80° C. and about 95° C.). For example, some PCR reactionsinclude a) incubation of a mixture including target molecules andprimers at high temperature (e.g., about 90° C. to about 95° C.) todenature the target DNA; b) cooling the mixture to an intermediatetemperature (e.g., about 50° C. to about 60° C.) to allow annealingbetween the primers and target DNA; and c) in the presence of DNApolymerase, generating extensions of the primers (e.g., by action of thepolymerase at, e.g. temperatures of about 65° C. to about 75° C.); andrepeating this cycle of steps a), b), and c). Steps a), b), and c)together may be termed a “thermal cycle”.

Amplification occurs with each thermal cycle, and, following multiplecycles, significant amplification of the target nucleic acid moleculeproduces large numbers of DNA copies of the target sequence. PCRrequirements include a DNA polymerase (e.g., a thermostable DNApolymerase), deoxynucleotides (typically as deoxynucleotidetri-phosphates (“dNTPs”) such as dATP, dTTP, dGTP, and dCTP), andappropriate buffer solutions. Where a target nucleic acid is an RNAtarget, reverse transcriptase (RT) may be used to produce a DNA copy ofthe RNA, and PCR applied to the DNA copies.

Reverse transcription PCR (RT-PCR) refers to methods for amplifying RNAtargets, in which copy DNA molecules (cDNAs) are produced from RNAtarget polynucleotides by application of reverse transcriptase, and PCRis applied to the cDNA copies to amplify the cDNA copies for detectionand/or amplification of the target polynucleotide. RT-PCR requirementsinclude a reverse transcriptase, a DNA polymerase (e.g., a thermostableDNA polymerase), deoxynucleotides (typically as dNTPs such as dATP,dTTP, dGTP, and dCTP), and appropriate buffer solutions.

Real-time PCR refers to PCR amplification methods in which the progress,or extent, of target amplification is monitored during the course of theassay (e.g., at each thermal cycle). Progress of the amplificationreactions may be monitored, for example, detecting the amount offluorescence or absorbance of reporter molecules. Suitable reportermolecules include intercalating dyes (which are detectable when bound todouble-stranded DNA, or to the minor groove of DNA, such as ethidiumbromide and SYBR Green dye); fluorogenic probes, such as self-quenchingdyes, or dye pairs (the pairs including a dye and a quencher) attachedto primers (which fluoresce when the primer is bound to target, but donot produce significant fluorescence when not hybridized to targetnucleic acid molecules); and other reporter molecules.

As used herein, “rRT-PCR” refers to reverse-transcription real-time PCR.rRT-PCR is real-time PCR applied to RNA targets, usingreverse-transcription PCR to amplify nucleic acids based on RNA targetmolecules, and monitoring the amplification using real-time PCR methods.Reverse-transcription PCR methods provide the DNA substrate required forPCR by contacting a sample, under the appropriate conditions, with areverse transcriptase and producing cDNA copies of RNA molecules in thesample.

NAA Methods

It will be understood that complete description of the isothermalnucleic acid amplification methods termed herein “NAA methods” is to befound in U.S. Patent Application Publication 2014/0295440, in U.S.Patent Application Publication 2015/0140567, in U.S. Patent ApplicationPublication 2016/0060673, in U.S. Patent Application Publication2016-0060674, in U.S. Patent Application Publication 2016/0076069, andin U.S. Patent Application Publication 2016/0201148 (each of which ishereby incorporated by reference in theirs entireties); however, thesemethods are also briefly summarized in the following.

NAA methods of nucleic acid amplification may be applied todouble-stranded DNA. However, target nucleic acid molecules need not belimited to double-stranded DNA targets; for example, double-stranded DNAfor use in NAA methods described herein may be prepared from viral RNA,or mRNA, or other single stranded RNA target sources, by reversetranscriptase. In further example, double-stranded DNA for use in NAAmethods described herein may be prepared from single-stranded DNAtargets by DNA polymerase. Such methods may be applied as an initialstep, prior to application of the NAA methods discussed below.

Amplification of a double-stranded DNA target, for example, begins witha primary double-stranded DNA to be amplified (termed the “primarynucleic acid” in the following). The primary nucleic acid contains atarget region termed a template region; the template region has atemplate sequence. Such a double-stranded template region contains afirst DNA strand and a complementary second DNA strand, and includes a5′ terminal nucleotide in one strand and a 3′ terminal nucleotide in theother strand that are complementary to each other.

A first primer and a second primer are provided which each havetemplate-binding regions and tail regions; the primer template-bindingregions are complementary to the target template regions. The tailregions of the primers may contain three components: a) the 5′ terminalnucleotide of the primer, b) an innermost nucleotide, wherein theinnermost nucleotide is downstream from the 5′ terminal nucleotide, andc) a middle section between the 5′ terminal nucleotide and the innermostnucleotide, comprising one or more nucleotides. In addition, at leastportions of the two primer tail regions may be complementary to eachother when properly aligned.

It should be noted that although the tail region of the second primermay contain a nucleotide sequence which is complementary to thenucleotide sequence of the tail region of the first primer, typically,products formed by the annealing of the first primer and second primerare not desirable or useful for methods or compositions provided herein.Accordingly, in some embodiments, steps may be taken to minimize theformation of first primer—second primer annealed products. Such stepsmay include, for example, not pre-incubating a first primer and a secondprimer under conditions where the primers may anneal for an extendedperiod of time before initiating a method provided herein.

The primary nucleic acid may be treated with a polymerase and a firstcopy of the first primer under conditions such that the template-bindingregion of the first copy of the first primer anneals to the first strandof the nucleic acid template. Under these conditions, an extensionproduct of the first copy of the first primer is formed. The polymerase,which may have strand displacement activity, may catalyze the formationof the extension product of the first copy of the first primer. Thefirst copy of the first primer may be covalently linked to thesynthesized extension product, such that the first copy of the firstprimer (which is complementary to the first strand of the nucleic acidtemplate) becomes part of the molecule described herein as the“extension product of the first copy of the first primer.” Thetemplate-binding region but not the tail region of the first copy of thefirst primer anneals to the first strand of the nucleic acid template.Examples of conditions suitable for polymerase-based nucleic acidsynthesis are known in the art and are provided, for example, inMolecular Cloning: A Laboratory Manual, M. R. Green and J. Sambrook,Cold Spring Harbor Laboratory Press (2012), which is incorporated byreference herein in its entirety.

The extension product of the first copy of the first primer may betreated with a polymerase (which may have strand displacement activity)and with the second primer under conditions such that thetemplate-binding region of the second primer anneals to the extensionproduct of the first copy of the first primer. In this way, an extensionproduct of the second primer may be formed. The polymerase may displacethe first strand of the nucleic acid template from the extension productof the first copy of the first primer during the synthesis of theextension product of the second primer. The second primer may becovalently linked to the synthesized extension product, such that thesecond primer becomes part of the molecule described herein as the“extension product of the second primer.” The extension product of thesecond primer is complementary to the extension product of the firstcopy of the first primer. The template-binding region but not the tailregion of the second primer may anneal to the extension product of thefirst copy of the first primer when the second primer anneals to theextension product of the first copy of the first primer.

The extension product of the second primer may be treated with apolymerase (which may have strand displacement activity) and a secondcopy of the first primer so as to form an extension product of thesecond copy of the first primer. During the generation of the extensionproduct of the second copy of the first primer, the second copy of thefirst primer may be covalently linked to the synthesized extensionproduct, such that the second copy of the first primer becomes part ofthe molecule described herein as the “extension product of the secondcopy of the first primer.” The extension product of the second copy ofthe first primer is complementary to the extension product of the secondprimer.

Generation of the extension product of the second copy of the firstprimer may result in the generation of a molecule comprising theextension product of the second copy of the first primer and theextension product of the second primer, which may be referred to hereinas the “secondary nucleic acid.” A secondary nucleic acid may comprisethe 3′ terminal region of the extension product of the second primer(and the complement thereof) and may comprise the 3′ terminal region ofthe extension product of the second copy of the first primer (and thecomplement thereof). Secondary nucleic acid molecules include sequencesof the template region adjacent to tail sequences. In embodiments,double-stranded nucleic acids are produced in which complementarytemplate and tail region sequences line up. In practice, multiple copies(e.g., two or more) of the secondary nucleic acid are produced by anyprocess whereby a nucleic acid having the general structure of thesecondary nucleic acid may be generated, including by practice of NAAmethods discussed herein.

Thus, pairs of copies of the secondary nucleic acid may be provided.Further numbers of copies may then be generated, for example, byrepetition of the foregoing steps and methods. For example, the fullprocess as described above for generating a secondary nucleic acid froma primary nucleic acid may be repeated two times, in order to generate atwo pairs of copies of the secondary nucleic acid; further repetitionsmay be performed to amplify the number of copies further, e.g., toexponentially amplify the number of copies (e.g., by powers of two).

In addition, since the secondary nucleic acid molecules includesequences of the template region adjacent to tail sequences, partiallydouble-stranded nucleic acids may be produced in which tail regionsequences hybridize and line up. Since these tail region sequences areattached to single-stranded template regions, a cross-over structurehaving two nucleic acid strands together held by the hybridized tailregion sequences is produced. These cross-over structures may beextended by a polymerase to form extension products of both componentstrands. These extension products which may be referred to as“concatemer strands.” Two concatemer strands may be annealed together,and may be collectively referred to as a concatemer; such concatemersmay contain two or more copies of the nucleic acid template.

In some embodiments, even longer concatemers may be formed. For example,concatemers may anneal together; or two concatemer molecules may form across-over structure similar to those formed by the shorter moleculestermed concatemer strands, as discussed above, followed by a largerconcatemer molecule containing four copies of the nucleic acid template.In another example, a secondary nucleic acid and a concatemer may form across-over structure, followed by a larger concatemer moleculecontaining three copies of the nucleic acid template. In someembodiments, multiple different concatemers of multiple differentlengths may be simultaneously generated.

Thus, concatemers generated according to such methods may be of anylength of nucleotides. In some embodiments, concatemer moleculesgenerated herein may be at least 30, 40, 50, 60, 70, 80, 90, 100, 150,200, 250, 300, 400, 500, 600, 700, 800, 900, 1000, 1500, 2000, 3000,4000, 5000, 6000, 7000, 8000, 9000, 10,000, 15,000, 20,000, or 25,000nucleotides in length. Concatemers generated according to such methodsmay contain any number of copies of a nucleic acid template. In someembodiments, concatemer molecules generated herein may contain at least2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 25,30, 35, 40, 45, 50, 60, 70, 80, 90, or 100 copies of a nucleic acidtemplate. Further examples are provided, and greater detail of these andother examples, is provided in U.S. Patent Application 61/800,606, filedMar. 15, 2013.

Detection of Reactions

Progress of a method provided herein may be monitored in multipledifferent ways. In one embodiment, a reaction may be assayed for anucleic acid amplification product (e.g. for the level of the product orthe rate of its generation). In another embodiment, a reaction may beassayed for the activity of a polymerase along a nucleic acid template(e.g. for movement of a polymerase along a template strand). Thus, insome embodiments, events of a method provided herein may observed due tothe accumulation of product from a method (which may be during or aftercompletion of steps of the method), or due to detectable eventsoccurring during the steps of a method.

The presence of amplified nucleic acids can be assayed, for example, bydetection of reaction products (amplified nucleic acids or reactionby-products) or by detection of probes associated with the reactionprogress.

In some embodiments, reaction products may be identified by staining theproducts with a dye. In some embodiments, a dye may have greaterfluorescence when bound to a nucleic acid than when not bound to anucleic acid. In some embodiments, a dye may intercalate with adouble-stranded nucleic acid or it may bind to an external region of anucleic acid. Nucleic acid dyes that may be used with methods andcompositions provided herein include, for example, cyanine dyes,PicoGreen®, OliGreen®, RiboGreen®, SYBR® dyes, SYBR® Gold, SYBR® GreenI, SYBR® Green II, ethidium bromide, dihydroethidium, BlueView™, TOTO®dyes, TO-PRO® dyes, POPO® dyes, YOYO® dyes, BOBO® dyes, JOJO® dyes,LOLO® dyes, SYTOX® dyes, SYTO® dyes, propidium iodide, hexidium iodide,methylene blue, DAPI, acridine orange, quinacrine, acridine dimers,9-amino-6-chloro-2-methoxyacridine, bisbenzimide dyes, Hoechst dyes,7-aminoactinomycin D, actinomycin D, hydroxystilbamidine, pyronin Y,Diamond™ dye, GelRed™, GelGreen™ and LDS 751.

Methods of detecting the presence of a target marker, such as, e.g. avirus such as a flu virus, a bacterium such as a Staphylococcus aureusbacterium, or other biological target may be detected in a sample aredisclosed herein, wherein the presence of a plurality of possibletargets are tested from a single sample within a short period of time.In embodiments, the plurality of possible targets comprise at least 5possible targets, or at least 10 possible targets, or at least 15possible targets, or at least 20 possible targets, or at least 25possible targets, or at least 30 possible targets, or at least 35possible targets, or at least 40 possible targets, or at least 45possible targets, or at least 50 possible targets, or at least 55possible targets, or at least 60 possible targets, or at least 64possible targets, or at least 65 possible targets, or more. Inembodiments, a short period of time is a period of time that is fivehours or less, or is four hours or less, or is three hours or less, oris two hours or less, or is one hour or less, or is 50 minutes or less,or is 40 minutes or less, or is 30 minutes or less, or is 20 minutes orless, or is 10 minutes or less, or is 5 minutes or less.

In some embodiments, reaction products may be identified by analysis ofturbidity of amplification reactions for example, where increasedturbidity is correlated with formation of reaction products and reactionby-products (e.g. pyrophosphate complexed with magnesium).

In some embodiments, reaction products may be identified by separating areaction performed according to a method herein by gel electrophoresis,followed by staining of the gel with a dye for nucleic acids. The dyemay be any nucleic acid dye disclosed herein or otherwise known in theart.

In some embodiments, any method or composition known in the art for thedetection of nucleic acids or processes associated with the generationof nucleic acids may be used with methods and compositions providedherein.

In some embodiments, a nucleic acid probe which contains a nucleotidesequence complementary to a portion of a nucleic acid template strand(or strand having a similar or identical sequence) and which containsone or both of a fluorescent reporter (fluorophore) and a quencher areincluded in a reaction provided herein.

In an example, a nucleic acid probe may contain a fluorescent reporterat its 5′ or 3′ terminus, and a quencher at the other terminus.

In another example, a nucleic acid probe may contain a fluorescentreporter at its 5′ or 3′ terminus, and it may be annealed to a nucleicacid primer containing a quencher. The nucleic acid primer containing aquencher may contain the quencher at a position in the primer such thatwhen the nucleic acid probe is annealed to the primer, the fluorescentreporter is quenched.

In probes containing a fluorescent reporter and quencher pair, thefluorescent reporter and quencher may be selected so that the quenchercan effectively quench the reporter. In some embodiments, a fluorescentreporter is paired with a quencher where the emission maximum of thefluorescent reporter is similar to the absorption maximum of thequencher. Fluorphores that may be used as the fluorescent reporterinclude, for example, CAL Fluor Gold, CAL Fluor Orange, Quasar 570, CALFluor Red 590, CAL Fluor Red 610, CAL Fluor Red 610, CAL Fluor Red 635,Quasar 670 (Biosearch Technologies), VIC, NED (Life Technologies), Cy3,Cy5, Cy5.5 (GE Healthcare Life Sciences), Oyster 556, Oyster 645(Integrated DNA Technologies), LC red 610, LC red 610, LC red 640, LCred 670, LC red 705 (Roche Applied Science), Texas red, FAM, TET, HEX,JOE, TMR, and ROX. Quenchers that may be used include, for example,DDQ-I, DDQ-II (Eurogentec), Eclipse (Epoch Biosciences), Iowa Black FQ,Iowa Black RQ (Integrated DNA Technologies), BHQ-1, BHQ-2, BHQ-3(Biosearch Technologies), QSY-7, QSY-21 (Molecular Probes), and Dabcyl.

In some embodiments, a method provided herein may be monitored in anapparatus containing a light source and an optical sensor. In somesituations, the reaction may be positioned in the path of light from thelight source, and light absorbed by the sample (e.g. in the case of aturbid reaction), scattered by the sample (e.g. in the case of a turbidreaction), or emitted by the sample (e.g. in the case of a reactioncontaining a fluorescent molecule) may be measured.

In embodiments, the sample may be diluted prior to testing for thepresence of a plurality of disease-causing agents. In embodiments, suchdilution of a sample is greater for subjects who have a condition whichindicates they may have higher levels of disease-causing agents thansubject who do not have that condition, or than subjects who have adifferent condition.

Systems and Devices for Detection of Targets in Samples

The assays and methods disclosed herein may be performed on a device, oron a system, for processing a sample. In embodiments, Applicantsdisclose herein systems and devices suitable for use in performingmethods disclosed herein. The assays and methods disclosed herein can bereadily incorporated into and used in device for processing a sample, ora system for processing a sample, which may be an automated assaydevice, or may be an automated assay system. Such a device, and such asystem, may be useful for the practice of the methods disclosed herein.For example, a device may be useful for receiving a sample. A device maybe useful for preparing, or for processing a sample. A device may beuseful for performing an assay on a sample. A device may be useful forobtaining data from a sample. A device may be useful for transmittingdata obtained from a sample. A device may be useful for disposing of asample following processing or assaying of a sample.

A device may be part of a system, a component of which may be anautomated assay device. A device may be an automated assay device. Anautomated assay device may be configured to facilitate collection of asample, prepare a sample for a clinical test, or effect a chemicalreaction with one or more reagents or other chemical or physicalprocessing, as disclosed herein. An automated assay device may beconfigured to obtain data from a sample. An automated assay device maybe configured to transmit data obtained from a sample. An automatedassay device may be configured to analyze data from a sample. Anautomated assay device may be configured to communicate with anotherdevice, or a laboratory, or an individual affiliated with a laboratory,to analyze data obtained from a sample.

An automated assay device may be configured to be placed in or on asubject. An automated assay device may be configured to accept a samplefrom a subject, either directly or indirectly. A sample may be, forexample, a blood sample (e.g., a sample obtained from a fingerstick, orfrom venipuncture, or an arterial blood sample), a urine sample, abiopsy sample, a tissue slice, stool sample, or other biological sample;a water sample, a soil sample, a food sample, an air sample; or othersample. A blood sample may comprise, e.g., whole blood, plasma, orserum. An automated assay device may receive a sample from the subjectthrough a housing of the device. The sample collection may occur at asample collection site, or elsewhere. The sample may be provided to thedevice at a sample collection site.

In some embodiments, an automated assay device may be configured toaccept or hold a cartridge. In some embodiments, an automated assaydevice may comprise a cartridge. The cartridge may be removable from theautomated assay device. In some embodiments, a sample may be provided tothe cartridge of the automated assay device. Alternatively, a sample maybe provided to another portion of an automated assay device. Thecartridge and/or device may comprise a sample collection unit that maybe configured to accept a sample.

A cartridge may include a sample, and may include reagents for use inprocessing or testing a sample, disposables for use in processing ortesting a sample, or other materials. Following placement of a cartridgeon, or insertion of a cartridge into, an automated assay device, one ormore components of the cartridge may be brought into fluid communicationwith other components of the automated assay device. For example, if asample is collected at a cartridge, the sample may be transferred toother portions of the automated assay device. Similarly, if one or morereagents are provided on a cartridge, the reagents may be transferred toother portions of the automated assay device, or other components of theautomated assay device may be brought to the reagents. In someembodiments, the reagents or components of a cartridge may remainon-board the cartridge. In some embodiments, no fluidics are includedthat require tubing or that require maintenance (e.g., manual orautomated maintenance).

A sample or reagent may be transferred to a device, such as an automatedassay device. A sample or reagent may be transferred within a device.Such transfer of sample or reagent may be accomplished without providinga continuous fluid pathway from cartridge to device. Such transfer ofsample or reagent may be accomplished without providing a continuousfluid pathway within a device. In embodiments, such transfer of sampleor reagent may be accomplished by a sample handling system (e.g., apipette); for example, a sample, reagent, or aliquot thereof may beaspirated into an open-tipped transfer component, such as a pipette tip,which may be operably connected to a sample handling system whichtransfers the tip, with the sample, reagent, or aliquot thereofcontained within the tip, to a location on or within the automated assaydevice. The sample, reagent, or aliquot thereof can be deposited at alocation on or within the automated assay device. Sample and reagent, ormultiple reagents, may be mixed using a sample handling system in asimilar manner. One or more components of the cartridge may betransferred in an automated fashion to other portions of the automatedassay device, and vice versa.

A device, such as an automated assay device, may have a fluid handlingsystem. A fluid handling system may perform, or may aid in performing,transport, dilution, extraction, aliquotting, mixing, and other actionswith a fluid, such as a sample. In some embodiments, a fluid handlingsystem may be contained within a device housing. A fluid handling systemmay permit the collection, delivery, processing and/or transport of afluid, dissolution of dry reagents, mixing of liquid and/or dry reagentswith a liquid, as well as collection, delivery, processing and/ortransport of non-fluidic components, samples, or materials. The fluidmay be a sample, a reagent, diluent, wash, dye, or any other fluid thatmay be used by the device, and may include, but not limited to,homogenous fluids, different liquids, emulsions, suspensions, and otherfluids. A fluid handling system, including without limitation a pipette,may also be used to transport vessels (with or without fluid containedtherein) around the device. The fluid handling system may dispense oraspirate a fluid. The sample may include one or more particulate orsolid matter floating within a fluid.

In embodiments, a fluid handling system may comprise a pipette, pipettetip, syringe, capillary, or other component. The fluid handling systemmay have portion with an interior surface and an exterior surface and anopen end. The fluid handling system may comprise a pipette, which mayinclude a pipette body and a pipette nozzle, and may comprise a pipettetip. A pipette tip may or may not be removable from a pipette nozzle. Inembodiments, a fluid handling system may use a pipette mated with apipette tip; a pipette tip may be disposable. A tip may form afluid-tight seal when mated with a pipette. A pipette tip may be usedonce, twice, or more times. In embodiments, a fluid handling system mayuse a pipette or similar device, with or without a pipette tip, toaspirate, dispense, mix, transport, or otherwise handle the fluid. Thefluid may be dispensed from the fluid handling system when desired. Thefluid may be contained within a pipette tip prior to being dispensed,e.g., from an orifice in the pipette tip. In embodiments, or instancesduring use, all of the fluid may be dispensed; in other embodiments, orinstances during use, a portion of the fluid within a tip may bedispensed. A pipette may selectively aspirate a fluid. The pipette mayaspirate a selected amount of fluid. The pipette may be capable ofactuating stirring mechanisms to mix the fluid within the tip or withina vessel. The pipette may incorporate tips or vessels creatingcontinuous flow loops for mixing, including of materials or reagentsthat are in non-liquid form. A pipette tip may also facilitate mixtureby metered delivery of multiple fluids simultaneously or in sequence,such as in 2-part substrate reactions.

The fluid handling system may include one or more fluidically isolatedor hydraulically independent units. For example, the fluid handlingsystem may include one, two, or more pipette tips. The pipette tips maybe configured to accept and confine a fluid. The tips may be fluidicallyisolated from or hydraulically independent of one another. The fluidcontained within each tip may be fluidically isolated or hydraulicallyindependent from one fluids in other tips and from other fluids withinthe device. The fluidically isolated or hydraulically independent unitsmay be movable relative to other portions of the device and/or oneanother. The fluidically isolated or hydraulically independent units maybe individually movable. A fluid handling system may comprise one ormore base or support. A base or support may support one or more pipetteor pipette units. A base or support may connect one or more pipettes ofthe fluid handling system to one another.

An automated assay device may be configured to perform processing stepsor actions on a sample obtained from a subject. Sample processing mayinclude sample preparation, including, e.g., sample dilution, divisionof a sample into aliquots, extraction, contact with a reagent,filtration, separation, centrifugation, or other preparatory orprocessing action or step. An automated assay device may be configuredto perform one or more sample preparation action or step on the sample.Optionally, a sample may be prepared for a chemical reaction and/orphysical processing step. A sample preparation action or step mayinclude one or more of the following: centrifugation, separation,filtration, dilution, enriching, purification, precipitation,incubation, pipetting, transport, chromatography, cell lysis, cytometry,pulverization, grinding, activation, ultrasonication, micro columnprocessing, processing with magnetic beads, processing withnanoparticles, or other sample preparation action or steps. For example,sample preparation may include one or more step to separate blood intoserum and/or particulate fractions, or to separate any other sample intovarious components. Sample preparation may include one or more step todilute and/or concentrate a sample, such as a blood sample, or otherbiological samples. Sample preparation may include adding ananti-coagulant or other ingredients to a sample. Sample preparation mayalso include purification of a sample. In embodiments, all sampleprocessing, preparation, or assay actions or steps are performed by asingle device. In embodiments, all sample processing, preparation, orassay actions or steps are performed within a housing of a singledevice. In embodiments, most sample processing, preparation, or assayactions or steps are performed by a single device, and may be performedwithin a housing of a single device. In embodiments, many sampleprocessing, preparation, or assay actions or steps are performed by asingle device, and may be performed within a housing of a single device.In embodiments, sample processing, preparation, or assay actions orsteps may be performed by more than one device.

An automated assay device may be configured to run one or more assay ona sample, and to obtain data from the sample. An assay may include oneor more physical or chemical treatments, and may include running one ormore chemical or physical reactions. An automated assay device may beconfigured to perform one, two or more assays on a small sample ofbodily fluid. One or more chemical reaction may take place on a samplehaving a volume, as described elsewhere herein. For example one or morechemical reaction may take place in a pill having less than femtolitervolumes. In an instance, the sample collection unit is configured toreceive a volume of the bodily fluid sample equivalent to a single dropor less of blood or interstitial fluid. In embodiments, the volume of asample may be a small volume, where a small volume may be a volume thatis less than about 1000 μL, or less than about 500 μL, or less thanabout 250 μL, or less than about 150 μL, or less than about 100 μL, orless than about 75 μL, or less than about 50 μL, or less than about 40μL, or less than about 20 μL, or less than about 10 μL, or other smallvolume. In embodiments, all sample assay actions or steps are performedon a single sample. In embodiments, all sample assay actions or stepsare performed by a single device. In embodiments, all sample assayactions or steps are performed within a housing of a single device. Inembodiments, most sample assay actions or steps are performed by asingle device, and may be performed within a housing of a single device.In embodiments, many sample assay actions or steps are performed by asingle device, and may be performed within a housing of a single device.In embodiments, sample processing, preparation, or assay actions orsteps may be performed by more than one device.

An automated assay device may be configured to perform a plurality ofassays on a sample. In embodiments, an automated assay device may beconfigured to perform a plurality of assays on a single sample. Inembodiments, an automated assay device may be configured to perform aplurality of assays on a single sample, where the sample is a smallsample. For example, a small sample may have a sample volume that is asmall volume of less than about 1000 μL, or less than about 500 μL, orless than about 250 μL, or less than about 150 μL, or less than about100 μL, or less than about 75 μL, or less than about 50 μL, or less thanabout 40 μL, or less than about 20 μL, or less than about 10 μL, orother small volume. An automated assay device may be capable ofperforming multiplexed assays on a single sample. A plurality of assaysmay be run simultaneously; may be run sequentially; or some assays maybe run simultaneously while others are run sequentially. One or morecontrol assays and/or calibrators (e.g., including a configuration witha control of a calibrator for the assay/tests) can also be incorporatedinto the device; control assays and assay on calibrators may beperformed simultaneously with assays performed on a sample, or may beperformed before or after assays performed on a sample, or anycombination thereof. In embodiments, all sample assay actions or stepsare performed by a single device. In embodiments, all of a plurality ofassay actions or steps are performed within a housing of a singledevice. In embodiments, most sample assay actions or steps, of aplurality of assays, are performed by a single device, and may beperformed within a housing of a single device. In embodiments, manysample assay actions or steps, of a plurality of assays, are performedby a single device, and may be performed within a housing of a singledevice. In embodiments, sample processing, preparation, or assay actionsor steps may be performed by more than one device.

In embodiments, all of a plurality of assays may be performed in a shorttime period. In embodiments, such a short time period comprises lessthan about three hours, or less than about two hours, or less than aboutone hour, or less than about 40 minutes, or less than about 30 minutes,or less than about 25 minutes, or less than about 20 minutes, or lessthan about 15 minutes, or less than about 10 minutes, or less than about5 minutes, or less than about 4 minutes, or less than about 3 minutes,or less than about 2 minutes, or less than about 1 minute, or othershort time period.

An automated assay device may perform nucleic acid assays, includingisothermal nucleic acid assays (e.g., assays for detecting and measuringnucleic acid targets in a sample, including DNA and RNA targets). Inembodiments, an automated assay device may perform nucleic acid assaysas disclosed in U.S. patent application Ser. No. 14/183,503, filed Feb.18, 2014; U.S. patent application Ser. No. 14/214,850, filed Mar. 15,2014; International Patent Application PCT/US2014/030034, filed Mar. 15,2014; and in International Patent Application PCT/US2014/056151, filedSep. 17, 2014. An automated assay device may perform antibody assays,including enzyme-linked immunosorbent assays (ELISA), and other assaysfor detecting and measuring the amounts of proteins (includingantibodies), peptides, and small molecules in samples. An automatedassay device may perform general chemistry assays, including electrolyteassays (e.g., assays for detecting and measuring the amounts ofelectrolytes such as sodium and potassium in a sample).

An automated assay device may be configured to detect one or moresignals relating to the sample. An automated assay device may beconfigured to identify one or more properties of the sample. Forinstance, the automated assay device may be configured to detect thepresence or concentration of one analyte or a plurality of analytes or adisease condition in the sample (e.g., in or through a bodily fluid,secretion, tissue, or other sample). Alternatively, the automated assaydevice may be configured to detect a signal or signals that may beanalyzed to detect the presence or concentration of one or more analytes(which may be indicative of a disease condition) or a disease conditionin the sample. The signals may be analyzed on board the device, or atanother location. Running a clinical test may or may not include anyanalysis or comparison of data collected.

A chemical reaction or other processing step may be performed, with orwithout the sample. Examples of steps, tests, or assays that may beprepared or run by the device may include, but are not limited toimmunoassay, nucleic acid assay, receptor-based assay, cytometric assay,colorimetric assay, enzymatic assay, electrophoretic assay,electrochemical assay, spectroscopic assay, chromatographic assay,microscopic assay, topographic assay, calorimetric assay, turbidmetricassay, agglutination assay, radioisotope assay, viscometric assay,coagulation assay, clotting time assay, protein synthesis assay,histological assay, culture assay, osmolarity assay, and/or other typesof assays, centrifugation, separation, filtration, dilution, enriching,purification, precipitation, pulverization, incubation, pipetting,transport, cell lysis, or other sample preparation action or steps, orcombinations thereof. Steps, tests, or assays that may be prepared orrun by the device may include imaging, including microscopy, cytometry,and other techniques preparing or utilizing images. Steps, tests, orassays that may be prepared or run by the device may further include anassessment of histology, morphology, kinematics, dynamics, and/or stateof a sample, which may include such assessment for cells.

A device, such as an automated sample analysis device, may be capable ofperforming all on-board steps (e.g., steps or actions performed by asingle device) in a short amount of time. A device may be capable ofperforming all on-board steps on a single sample in a short amount oftime. For example, from sample collection from a subject to transmittingdata and/or to analysis may take about 3 hours or less, 2 hours or less,1 hour or less, 50 minutes or less, 45 minutes or less, 40 minutes orless, 30 minutes or less, 20 minutes or less, 15 minutes or less, 10minutes or less, 5 minutes or less, 4 minutes or less, 3 minutes orless, 2 minutes or less, or 1 minute or less. The amount of time fromaccepting a sample within the device to transmitting data and/or toanalysis from the device regarding such a sample may depend on the typeor number of steps, tests, or assays performed on the sample. The amountof time from accepting a sample within the device to transmitting dataand/or to analysis from the device regarding such a sample may takeabout 3 hours or less, 2 hours or less, 1 hour or less, 50 minutes orless, 45 minutes or less, 40 minutes or less, 30 minutes or less, 20minutes or less, 15 minutes or less, 10 minutes or less, 5 minutes orless, 4 minutes or less, 3 minutes or less, 2 minutes or less, or 1minute or less.

A device may be configured to prepare a sample for disposal, or todispose of a sample, such as a biological sample, following processingor assaying of a sample.

In embodiments, an automated assay device may be configured to transmitdata obtained from a sample. In embodiments, an automated assay devicemay be configured to communicate over a network. An automated assaydevice may include a communication module that may interface with thenetwork. An automated assay device may be connected to the network via awired connection or wirelessly. The network may be a local area network(LAN) or a wide area network (WAN) such as the Internet. In someembodiments, the network may be a personal area network. The network mayinclude the cloud. The automated assay device may be connected to thenetwork without requiring an intermediary device, or an intermediarydevice may be required to connect an automated assay device to anetwork. An automated assay device may communicate over a network withanother device, which may be any type of networked device, including butnot limited to a personal computer, server computer, or laptop computer;personal digital assistants (PDAs) such as a Windows CE device; phonessuch as cellular phones, smartphones (e.g., iPhone, Android, Blackberry,etc.), or location-aware portable phones (such as GPS); a roamingdevice, such as a network-connected roaming device; a wireless devicesuch as a wireless email device or other device capable of communicatingwireless with a computer network; or any other type of network devicethat may communicate possibly over a network and handle electronictransactions. Such communication may include providing data to a cloudcomputing infrastructure or any other type of data storageinfrastructure which may be accessed by other devices.

An automated assay device may provide data regarding a sample to, e.g.,a health care professional, a health care professional location, such asa laboratory, or an affiliate thereof. One or more of a laboratory,health care professional, or subject may have a network device able toreceive or access data provided by the automated assay device. Anautomated assay device may be configured to provide data regarding asample to a database. An automated assay device may be configured toprovide data regarding a sample to an electronic medical records system,to a laboratory information system, to a laboratory automation system,or other system or software. An automated assay device may provide datain the form of a report.

A laboratory, device, or other entity or software may perform analysison data regarding a sample in real-time. A software system may performchemical analysis and/or pathological analysis, or these could bedistributed amongst combinations of lab, clinical, and specialty orexpert personnel. Analysis may include qualitative and/or quantitativeevaluation of a sample. Data analysis may include a subsequentqualitative and/or quantitative evaluation of a sample. Optionally, areport may be generated based on raw data, pre-processed data, oranalyzed data. Such a report may be prepared so as to maintainconfidentiality of the data obtained from the sample, the identity andother information regarding the subject from whom a sample was obtained,analysis of the data, and other confidential information. The reportand/or the data may be transmitted to a health care professional. Dataobtained by an automated assay device, or analysis of such data, orreports, may be provided to a database, an electronic medical recordssystem, to a laboratory information system (LIS), to a laboratoryautomation system (LAS), or other system or software.

An example of an integrated system disclosed herein comprises anintegrated system for providing testing and diagnosis of a subjectsuspected of suffering from a disease, said system comprising a meansfor obtaining a sample (which may include, e.g., a sample collectiondevice comprising a lancet, a syringe, a needle and tube, or other bloodcollection device; or a nasal swab, a mouth swab (e.g., a cheek swab), athroat swab, a vaginal swab, or other swab, and fluid in which toimmerse the swab following contacting the swab with a subject); acartridge comprising reagents for assays for the disease; a device forrunning a plurality of assays for detecting a plurality of diseases; adevice/means for displaying/communicating the detection of one or moreof said diseases. Such integrated systems may be configured for useswherein the sample is a small volume sample; for uses wherein detectionis performed in a short period of time; or for uses both wherein thesample is a small volume sample and wherein detection is performed in ashort period of time.

Another example of an integrated system disclosed herein comprises anintegrated system for providing testing and diagnosis of a subjectsuspected of suffering from a respiratory disorder, said systemcomprising a means for obtaining a sample (which may include, e.g., anasal swab, a throat swab, a mouth swab (e.g., a cheek swab), a vaginalswab, or other swab, and fluid in which to immerse the swab followingcontacting the swab with a subject); a cartridge comprising reagents forassays for respiratory disorders; a device for running a plurality ofassays for detecting a plurality of respiratory disorders; adevice/means for displaying/communicating the detection of one or moreof said respiratory disorders. Such integrated systems may be configuredfor uses wherein the sample is a small volume sample; for uses whereindetection is performed in a short period of time; or for uses bothwherein the sample is a small volume sample and wherein detection isperformed in a short period of time.

A further example of an integrated system disclosed herein comprises anintegrated system for providing testing, diagnosis, and prescription ofa subject suspected of suffering from a respiratory disorder, saidsystem comprising a means for obtaining a sample (which may include,e.g., a nasal swab, a throat swab, a mouth swab (e.g., a cheek swab), avaginal swab, or other swab, and fluid in which to immerse the swabfollowing contacting the swab with a subject); a cartridge comprisingreagents for assays for respiratory disorders; a device for running aplurality of assays for detecting a plurality of respiratory disorders;a device/means for displaying/communicating the detection of one or moreof said respiratory disorders; and means for providing a prescriptionfor the treatment of a respiratory disorder detected in said sample.Such integrated systems may be configured for uses wherein the sample isa small volume sample; for uses wherein detection is performed in ashort period of time; or for uses both wherein the sample is a smallvolume sample and wherein detection is performed in a short period oftime.

A yet further example of an integrated system as disclosed hereincomprises an integrated system for providing testing, diagnosis,prescription, and treatment of a subject suspected of suffering from arespiratory disorder, said system comprising a means for obtaining asample (which may include, e.g., a nasal swab, a throat swab, a mouthswab (e.g., a cheek swab), a vaginal swab, or other swab, and fluid inwhich to immerse the swab following contacting the swab with a subject);a cartridge comprising reagents for assays for respiratory disorders; adevice for running a plurality of assays for detecting a plurality ofrespiratory disorders; a device/means for displaying/communicating thedetection of one or more of said respiratory disorders; means forproviding a prescription for the treatment of a respiratory disorderdetected in said sample; and means for providing/selling/delivering atreatment (drug/pill/shot) to said subject pursuant to saidprescription. Such integrated systems may be configured for uses whereinthe sample is a small volume sample; for uses wherein detection isperformed in a short period of time; or for uses both wherein the sampleis a small volume sample and wherein detection is performed in a shortperiod of time.

Description and disclosure of examples of reagents, assays, methods,kits, devices, and systems which may use, or be used with, the methods,devices, and systems disclosed herein may be found, for example, in U.S.Pat. Nos. 8,088,593; 8,380,541; 8,435,738; 8,475,739; 8,840,838; U.S.patent application Ser. No. 14/183,503, filed Feb. 18, 2014; U.S. patentapplication Ser. No. 13/933,035, filed Jul. 1, 2013; U.S. patentapplication Ser. No. 13/769,820, filed Feb. 18, 2013; U.S. patentapplication Ser. No. 14/183,503, filed Feb. 18, 2014; Patent applicationSer. No. 14/214,850, filed Mar. 15, 2014; International PatentApplication PCT/US2014/030034, filed Mar. 15, 2014; International PatentApplication PCT/US2014/056151, filed Sep. 17, 2014; U.S. patentapplication Ser. No. 13/769,798, filed Feb. 18, 2013; U.S. patentapplication Ser. No. 13/769,779, filed Feb. 18, 2013; U.S. patentapplication Ser. No. 13/244,947 filed Sep. 26, 2011; PCT/US2012/57155,filed Sep. 25, 2012; U.S. application Ser. No. 13/244,946, filed Sep.26, 2011; U.S. patent application Ser. No. 13/244,949, filed Sep. 26,2011; and U.S. application Ser. No. 13/945,202, filed Jul. 18, 2013, thedisclosures of which patents and patent applications are all herebyincorporated by reference in their entireties.

EXAMPLES

The following examples are offered for illustrative purposes only, andare not intended to limit the present disclosure in any way.

Example 1

Thermocycling pre-amplification methods include any suitablethermocycling method, including PCR, reverse-transcriptase PCR (rtPCR),and other PCR methods. Two-step PCR methods include methods with stepsof incubating at a first temperature (e.g., between about 38-45° C., orabout 42° C.); incubating at a second, raised temperature (e.g., betweenabout 90-105° C., or about 98° C.); thermal cycling between twotemperatures where the two temperatures are a) a second, raisedtemperature (e.g., between about 90-105° C., or about 98° C.) and b) alower, annealing temperature (Tm, e.g., between about 50° C. to about80° C.); and then incubating at a third, lower temperature (e.g., atemperature between about 65° C. to about 75° C.). Three-step PCRmethods include methods with steps of incubating at a first temperature(e.g., between about 38-45° C., or about 42° C.); incubating at asecond, raised temperature (e.g., between about 90-105° C., or about 98°C.); thermal cycling between three temperatures where the threetemperatures are a) a second, raised temperature (e.g., between about90-105° C., or about 98° C.) and b) a lower, annealing temperature (Tm,e.g., between about 50° C. to about 80° C.); and c) a third, lowertemperature (e.g., a temperature between about 65° C. to about 75° C.);and then, an incubation at a third, lower temperature (e.g., atemperature between about 65° C. to about 75° C.). Following the lastincubation at the third, lower temperature, the amplified sample may beused immediately, or may be stored (e.g., at 4° C.) until needed.

A method as provided herein was performed as follows:

PCR thermal cycling was performed on a sample, where the sample wassubjected to thermal cycling as follows:

1) incubated for 30 minutes at 42° C., then

2) incubated at 98° C. for 2 minutes, followed by

3) 35 repeated thermal cycles as follows:

-   -   i) 10 seconds at 98° Cm, followed by    -   ii) 15 seconds at Tm ° C., followed by    -   iii) 15 seconds at 72° C.; and then, after the 35 cycles,

4) incubated for 2 minutes at 72° C.

In alternative embodiments, the number of repeated cycles in step 3)above may be altered; for example, the number of repeated cycles may bereduced to, e.g., 30, or 25, or 20, or fewer cycles. In otheralternative embodiments, the number of repeated cycles in step 3) abovemay be increased, e.g., to 40, or 45, or 50, or more cycles. Inalternative embodiments, step iii) above may be shortened to less than15 seconds, or may be eliminated altogether. Where step iii) iseliminated, the PCR method becomes a “two-step” PCR method.

Following the above steps 1 to 4, the amplified sample can beimmediately used for isothermal amplification (e.g., by NAA methods) ormay be stored at 4° C. until needed. Steps 1) to 4) take approximatelyone hour to complete. The “Tm” indicates the annealing temperature for aparticular primer set; a primer set may have a different Tm than otherprimer sets, or may have the same Tm as another primer set. In manycases, Tm is typically between about 50° C. to about 75° C. For example,in the experiments shown in the figures, Tm was 62° C. for RLX3539/40primers, and was 72° C. for RLX3547/48 primers.

Primers directed to nucleic acid sequences present in Ebola virus weredeveloped and synthesized. Two primer sets were used in the experimentsdisclosed herein. Experiments were performed in order to determine thelimit of detection (LOD) of target Ebola virus nucleic acid targetsequences. These experiments were performed with both pre-amplificationprimer sets RLX3539/40 and RLX3547/48. For the primer set RLX3539/40, anannealing temperature of 61° C. was used. An annealing temperature of62° C. may also be used with this primer set. An annealing temperatureof 71° C. was used for primer set RLX3547/48.

In embodiments, the primers used for the PCR and the NAA methods may benested primers, where the nucleic acid targets of one set of primers areinternal to (encompassed within) the nucleic acid sequences amplified bythe other set of primers. For example, primers used for NAAamplification may be targeted to nucleic acid sequences that areamplified during PCR amplification, i.e., the NAA target nucleic acidsare internal to the target nucleic acids to which the PCR primershybridize.

Primer set RLX3539/40 had the following nucleic acid sequence:

RLX3539 (SEQ ID NO: 1) TGCCAACTTATCATACAGGC RLX3540 (SEQ ID NO: 2)GACTGCGCCACTTTCC

Primer set RLX3547/48 had the following nucleic acid sequence:

RLX3547 (SEQ ID NO: 3) TGCCAACTTATCATACAGGCCTT RLX3548 (SEQ ID NO: 4)TGCCCTTCCAAATACTTGACTGCGCCA

In the “pre-amplification” experiments shown in the figures, rtPCR wasused to amplify RNA target nucleic acids in a sample; target nucleicacids were included with PCR reagents to a final concentration of 10³,10², 10, 5, and 1 copy per microliter (4), and PCR amplificationperformed; 2.5 μL of the resulting reagent, following the amplification,was combined with NAA reagents and isothermal NAA amplificationperformed. In the “control—no pre-amplification” experiments, targetnucleic acids were included with NAA reagents to a final concentrationof 10³, 10², 10, 5, and 1 copy per microliter (4), and isothermal NAAamplification was performed. As shown in the figures, these methodscombining PCR pre-amplification with NAA isothermal amplification wereable to achieve an LoD of 1 copy/4 (shown as “1c/uL” in the figures);such an LoD means there were 5 copies/RT PCR reaction. See results belowfor both primers sets.

Detection of target is indicated by the inflection time measured in theNAA assay (note that “NTC” (no-template control) shows an inflection,but at much later times than a specific signal detected for targetsequences). Primer set RLX3539/40 was used for the RT-PCRpre-amplification in the experiments shown in FIGS. 1 and 2. As shown inFIG. 1, target nucleic acid sequences were detected in 20 minutes orless for all copy numbers in samples with RT-PCR pre-amplification (leftfive columns, displaying inflection times for 10³, 10², 10, 5, and 1copy per microliter (4)). In contrast, the inflection times for controlexperiments (NAA assays without RT-PCR pre-amplification, shown on theright) were all greater than about 35 minutes (all but one were greaterthan 60 minutes; the shortest inflection time being for the greatestnumber of copies (10³ copies/μL). Thus, target nucleic acid sequences insamples were more readily detected by the isothermal NAA methods asdisclosed herein when the sample was first “pre-amplified” by PCR(results labeled “pre-amplification”), than by the NAA isothermalmethods alone.

FIG. 2 shows some raw output of the experiments summarized in FIG. 1.The traces shown in FIG. 2 are from NAA assays performed followingpre-amplification, with relative fluorescence shown in the verticaldirection, and time (as “cycles”, where a cycle is about 60 to 90seconds, i.e., approximately about one minute) in the horizontaldirection.

Primer set RLX3547/48 was used for the RT-PCR pre-amplification in theexperiments shown in FIGS. 3, 4, and 5. As shown in FIG. 3, targetnucleic acid sequences were detected in about 30 minutes or less for allcopy numbers in samples with RT-PCR pre-amplification (left fivecolumns, displaying inflection times for 10³, 10², 10, 5, and 1 copy permicroliter (4)). In contrast, the inflection times for controlexperiments (NAA assays without RT-PCR pre-amplification, shown on theright) were all greater than about 35 minutes, and all but one, for 10³copies/μL, were greater than 60 minutes. Thus, in these experiments aswell, when the sample was first “pre-amplified” by PCR, target nucleicacid sequences in samples were more readily detected by the isothermalNAA methods than by the NAA isothermal methods alone.

FIG. 4 shows some raw output from the NAA assays with pre-amplification(summarized in FIG. 3), with relative fluorescence shown in the verticaldirection, and time (as “cycles”, where a cycle is about 60 to 90seconds, i.e., approximately about one minute) in the horizontaldirection. In contrast, FIG. 5 shows some raw output from the NAA assayswith no pre-amplification (summarized in FIG. 3), with relativefluorescence shown in the vertical direction, and time (as “cycles”,where a cycle is about 60 to 90 seconds, i.e., approximately about oneminute) in the horizontal direction. Comparison of the traces in FIG. 4and FIG. 5 illustrates the reduced time for detection (shorterinflection time) when NAA isothermal methods are preceded by RT-PCR ascompared to the time for detection (inflection time) for NAA isothermalmethods alone (in the absence of RT-PCR pre-amplification).

Example 2

In one non-limiting example, rapid identification of acute andestablished HIV infection using a single test that is capable ofdetecting HIV nucleic acids, antibodies, and antigens can have adramatic impact on public health by helping patients with positive HIVresults obtain the care and services they need faster. In oneembodiment, a single test for HIV is provided that is capable ofdetecting HIV nucleic acids, antibodies, and antigens (for bothdiagnostic and prognostic use), is simple to use on specimens, processedor unprocessed, capable of either or both qualitative and quantitativeapplications, may be performed in 5 hrs or less, 4 hrs or less, 3 hrs orless, 2 hrs or less, or 60 minutes or less, and suitable for commercialdistribution.

In one embodiment, an HIV test of the invention tests for all of thefollowing from a sample obtained from a subject in a single device orwith the housing of one device: HIV-1 RNA, HIV-2 RNA, p24 antigen, HIV-1antibodies, and HIV-2 antibodies. Thus, the HIV test of the invention isalso capable of differentiating between HIV-1 and HIV-2 infection. Inone embodiment, a simplified sixth-generation HIV test comprisesperforming all the following tests from one small sample: HIV-1 RNA,HIV-2 RNA, p24 antigen, HIV-1 IgG, HIV-2 IgG, HIV-1 IgM, and HIV-2 IgM.

In one non-limiting example, the sample may be between about 100 toabout 200 microliters of blood (venous or capillary). In anothernon-limiting example, the small sample may be between about 10 to about100 microliters of blood (venous or capillary). In some embodiments, theblood is pre-processed so that the sample being tested is plasma. Insome embodiments, the blood is pre-processed so that the sample beingtested is serum. In some embodiments, the blood is pre-processed so thatthe sample being tested is diluted blood. In some embodiments, thesample being tested is undiluted blood. In some embodiments, thepre-processing occurs on a device separate from the sample processingdevice. Optionally, the pre-processing and sample processing both occurin one device or within the housing of one device. In an embodiment, theHIV-1 RNA, HIV-2 RNA, p24 antigen, HIV-1 antibodies, and HIV-2antibodies are tested from a single sample obtained from the subject.

In one non-limiting example, by combining nucleic acid testing andserological testing, this embodiment of the test will provideinformation to detect acute infections as well as for establishedinfections. Optionally, this HIV test is fully automated and will haveon-board quality controls (QC) that are processed in parallel with thepatient sample. In one embodiment of the on-board QC, the on-boardquality controls will include positive and negative controls as well asthe human RNaseP gene to act as a positive control with human clinicalspecimens to indicate that adequate isolation of nucleic acid resultedfrom the extraction of the clinical specimen. In one non-limitingexample the QC reagents and consumables are contained in the samecartridge that has the reagents and consumables for the HIV test.

In one non-limiting example, this HIV test is designed to be run from acapillary whole-blood sample. Optionally, in a still further embodiment,it should be understood that the test can be configured to run oncapillary or venous whole blood, serum, or plasma. In one embodiment,the test is processed automatically by a sample processing without anyuser intervention. In one embodiment, the test is processedautomatically by a sample processing without any user intervention afterloading of the sample into the device. Given the ease of samplecollection, the ease of running the sample, the high sensitivity/highspecificity nucleic acid, antigen, and serologic testing, thisembodiment of the test can be used for rapid diagnosis anddifferentiation of HIV-1 and HIV-2 infections.

By way of one non-limiting example, the steps of processing a sample maycomprise

-   -   a. RNA extraction from the sample by a beads-based method is        performed;    -   b. Reverse transcription (RT) is performed;    -   c. Pre-amplification is performed through a series of polymerase        chain reaction (PCR) amplification cycles,    -   d. Isothermal amplification and detection are performed;    -   e. Immunoassays to detect p24, HIV-1 antibodies, and HIV-2        antibodies are performed in parallel to the above nucleic acid        testing;    -   f. On-board controls are processed in parallel to the sample        processing on the instrument.

The immunoassays may be direct or indirect immunoassays and may be anELISA (enzyme-linked immunosorbent assay). For example, p24 may bedetecting using an antibody-sandwich immunoassay using a monoclonalantibody specific for p24. The HIV test of the invention may also becapable of detecting IgG, IgM, or both, antibodies of HIV-1 and HIV-2.In a particular embodiment, the test of the invention is capable ofdetecting both IgG and IgM antibodies of HIV-1 and HIV-2. In anon-limiting example, both the IgG and IgM antibodies are detected usingantigen sandwich immunoassays for HIV-1 and HIV-2. In an embodiment, theimmunoassays are capable of distinguishing between HIV-1 and HIV-2antibodies by, for example, using antigens specific for HIV-1 and HIV-2,respectively. In another embodiment, the HIV tests are capable ofdistinguishing between antigen reactivity and antibody reactivity by,for example, using different detection reagents, performing the assaysseparately from one another, and/or different detection methods. Thecapture reagent (eg. antigen, antibody, etc.) may be immobilized on asolid support, including but not limited to, beads, surface of wells,and inside assay tips.

Further, although many of embodiments herein describe nucleic acidamplification using an isothermal technique, it should be understoodthat other nucleic acid amplification techniques such as PCR, qPCR,nested PCR, or other nucleic acid detection techniques are not excluded.In another embodiment, the test is capable of distinguishing betweenHIV-1 and HIV-2 RNA by using primers that are specific to HIV-1 andHIV-2, respectively.

In one non-limiting example, raw data from the testing is transmitted toa data analyzer for interpretation. In one embodiment, the data analyzeris not at the same location as the device that processes the sampleusing the above steps. Optionally, other embodiments may have the dataanalyzer in the same location as the sample processor. Optionally, otherembodiments may combine the data analyzer and the sample processor inthe same device. It should also be understood that in some embodiments,the raw data is in the form of voltage, current, numeric, electronic,optical, digital, or other non-final value that, if intercepted byanother party or device, is meaningless unless the intercepting party ordevice has conversion information or an algorithm to convert such rawdata or other readout into health measurements.

In one embodiment, test cartridges are stored refrigerated (4-8° C.)prior to use. Optionally, the test cartridges are stored refrigerated(2-10° C.) prior to use. In one embodiment, the test uses a singlecartridge that provides all reagents and consumables used for at leastthe nucleic acid testing and serological testing. Optionally, thecombined test uses a single cartridge that provides all reagents andconsumables used for the nucleic acid testing, antibody testing, andantigen testing. Optionally, the combined test uses a single cartridgethat provides all reagents and consumables used for the nucleic acidtesting, antibody testing, and antigen testing on blood and a tissuesample contained in the cartridge. Optionally, the combined test uses asingle cartridge that provides all reagents and consumables used for thenucleic acid testing, antibody testing, and antigen testing on blood anda sample on a nasal swab contained in the cartridge. Optionally, thecombined test uses a single cartridge that provides all reagents andconsumables used for the nucleic acid testing, antibody testing, andantigen testing on blood and a sample on a throat swab contained in thecartridge. Optionally, the combined test uses a single cartridge thatprovides all reagents and consumables used for the nucleic acid testing,antibody testing, and antigen testing on capillary blood. Optionally,the combined test uses a single cartridge that provides all reagents andconsumables used for the nucleic acid testing, antibody testing, andantigen testing on diluted capillary blood. Optionally, the combinedtest uses a single cartridge that provides all reagents and consumablesused for the nucleic acid testing, antibody testing, and antigen testingon diluted venous blood. Optionally, the combined test uses a singlecartridge that provides all reagents and consumables used for thenucleic acid testing, antibody testing, and antigen testing on venousblood.

The HIV test, as described in one embodiment herein, can be deployed aturgent care centers with trained and certified medical staff on-site toperform finger-stick tests and collect samples. Optionally, some mayhave these test available at locations at retail pharmacies, retailstores, or other locations accessible at location that subjects mayvisit for other purposes (shopping or the like) during hours whenregular doctor offices are closed or even when the doctor offices areopen.

In one embodiment, fully automated production facilities can support theproduction of tests in extremely high volumes (sufficient for processingtens of millions of samples).

In one non-limiting example, the sensitivity of the HIV test will becomparable to if not more sensitive than other FDA-approved nucleic acidtests such as the Abbott RealTime HIV-1 test. In one embodiment, thelimit of detection (LOD) may be as low as 5, 8, 10, 15, 20, 50, 100,500, or 1000 HIV copies in a sample.

In one embodiment herein, the nucleic acid tests are highly-sensitivefor low copy number sensitivity that can be used for rapid diagnosisduring acute infection. By way of non-limiting example, the nucleic acidtests in this embodiment are specific to HIV-1 Group M (A-H) and Group0, and HIV-2 subtypes A and B, respectively.

In one embodiment of the test herein, the turnaround time may be a runtime that is less than 60 minutes. The traditional turnaround time forexisting nucleic acid testing is 6.5 hours (3.5 hours for extraction and3 hours for amplification and detection) for individual or poolednucleic acid testing.

In terms of CLIA status and test complexity, given the ease of samplecollection, on-board QC, automated sample processing, and automatedanalysis and results interpretation, the HIV may be configured for aCLIA waiver or similar waiver from other regulatory body regarding testcomplexity, while some may opt to run it through CLIA certified or otherregulatory agency certified laboratories.

The embodiments herein may dramatically improve the ability to rapidlyidentify acute and established HIV infection through simplified nucleicacid tests for detecting and quantifying HIV, and thus allow patients toreceive care and services faster.

In some embodiments, the HIV test uses a quantitative nucleic acidamplification process. Optionally, some embodiments may use aqualitative nucleic acid amplification process.

Example 3 MRSA DETECTION

Methicillin-resistant Staphylococcus aureus (MRSA) is a type ofStaphylococcus aureus (S. aureus) which can cause infection in humansand is resistant to beta-lactam antibiotics. As a result of itsresistance to certain antibiotics, MRSA infections can be difficult totreat.

S. aureus bacteria typically become methicillin-resistant throughacquiring the mecA gene. The mecA gene is typically located in thestaphyloccal cassette chromosome mec (SCCmec), which is a multi-gene,transferrable genomic element. Different types of SCCmec exist, withknown SCCmec types ranging in size from approximately 21,000-67,000nucleotides in length. Generally, within each type of SCCmec, the mecAgene is surrounded by other genes or elements which are other componentsof the SCCmec. In MRSA bacteria, SCCmec containing the mecA gene isintegrated into the S. aureus chromosome.

In order identify and control MRSA bacteria, effective reagents andmethods for MRSA detection are needed.

Provided herein are systems and methods for MRSA detection. Variousfeatures described herein may be applied to any of the particularembodiments set forth below or for any other types systems for orinvolving MRSA detection. Systems and methods described herein may beapplied as a standalone system or method, or as part of an integratedsystem or method. It shall be understood that different aspects of thedisclosed systems and methods can be appreciated individually,collectively, or in combination with each other.

Prior methods for MRSA detection typically separately test a sample forthe mecA gene and for genetic material from the S. aureus chromosome. Ifboth the mecA gene and S. aureus genetic material are found in thesample, a presumptive conclusion is made that MRSA is present. However,this conclusion might not be accurate, because the mecA gene can existoutside of S. aureus (as part of the SCCmec, which is transferrablebetween organisms). Thus, a sample that contains both the mecA gene andS. aureus might not actually contain MRSA; instead, it may containnon-MRSA S. aureus bacteria, and a different bacteria or free geneticelement which contains the mecA gene. This situation thus may give riseto a false-positive identification of MRSA in a sample.

Methods and compositions provided herein address the above problem, andprovide methods and compositions for identifying the mecA gene in a S.aureus chromosome (and thus, true MRSA).

One approach to identifying a mecA gene in a S. aureus chromosome mightbe to perform, for example, polymerase chain reaction (PCR), where thePCR reaction would contain a sample which might contain MRSA bacteria orMRSA genetic material, and wherein one of the primers for the PCRreaction would anneal to portion of the mecA gene and the other primerfor the PCR reaction would anneal to a portion of the S. aureuschromosome. If such a PCR reaction yielded a reaction product, it wouldindicate that both the mecA gene and genetic material from the S. aureuschromosome were on the same strand (and thus, that the sample containedtrue MRSA bacteria). However, typically this approach is not effective,because in most MRSA bacteria, the mecA gene is many thousands ofnucleotides away from genetic material of the S. aureus chromosome. Thisis due to the fact that in MRSA, the mecA gene is integrated into the S.aureus chromosome as part of the SCCmec, and the mecA gene is typicallyin an inner portion of the SCCmec, surrounded on both sides by thousandsof additional nucleic acids of the SCCmec insert. The relatively largenucleotide distance between the mecA gene and the S. aureus chromosomein most MRSA strains generally results in the poor performance oftraditional PCR reactions as described above (e.g. with one primerannealing to a portion of the mecA gene and the other primer annealingto a portion of the S. aureus chromosome), as traditional PCR and manyother nucleic acid amplification techniques are not very effective atamplifying relatively long nucleotide sequences.

Multiple different types of SCCmec have been identified. For instance,the position of the mecA gene may differ between the different SCCmectypes; the content of the SCCmec elements may differ between thedifferent SCCmec types, and the locations in the S. aureus chromosomewhere the SCCmec are inserted (e.g. attL and attR) may differ betweenthe different SCCmec types. The mecA gene when present in a S. aureuschromosome is typically separated from S. aureus genetic material bythousands or even tens of thousands of nucleotides.

Provided herein are improved methods and compositions for identifyingthe mecA gene in a S. aureus chromosome (and thus, true MRSA).

In embodiments, methods provided herein comprise at least two steps: 1)a step to generate a nucleic acid strand wherein at least a portion ofthe mecA gene and the S. aureus chromosome are in close physicalproximity to each other within the strand; and 2) a step to perform anucleic acid amplification method using at least a first primer, asecond primer and the nucleic acid strand of step 1), wherein the firstprimer anneals to a portion of the mecA gene and the second primeranneals to a portion of the S. aureus chromosome, and where anamplification product is generated which includes portions of both themecA gene and the S. aureus chromosome.

In embodiments of systems and methods provided herein, a S. aureuschromosome or portion thereof containing a SCCmec cassette containing amecA gene 200 may be provided (referred to as a “MRSA chromosome”). TheMRSA chromosome 200 may be incubated with a first primer and a secondprimer, wherein the first primer is complementary to a portion of themecA gene (or, optionally, other element of the SCCmec cassette), andthe second primer is complementary to a portion of the S. aureuschromosome. In addition, one or both of the primers is phosphorylated atthe 5′ end. The MRSA chrosomosome is incubated in a first DNAamplification reaction with a DNA polymerase having high processivity.An exemplary DNA polymerase with high processivity is phi29 polymerase.The first DNA amplification reaction may be, for instance, an isothermalmethod. By use of a DNA polymerase with high processivity, at least asmall amount of amplification product 202 may be generated. Theamplification product from this reaction 202 will contain both S. aureusand mecA genetic material, but typically, only a small amount ofamplified material 202 will be generated. This amplified material 202 isgenerally difficult to detect, due to the small amount generated.Accordingly, the amplified material 202 is then incubated with a DNAligase, which can ligate amplification products 202 together due to thephosphate groups on the 5′ end of the primers used for the amplificationreaction. Incubation of the amplified material 202 with a ligase mayresult in two general types of ligation products: a) concatemers 204formed by the end-to-end ligation of two or more amplification products202; or b) circularized products 206 formed by the ligation of one endof an amplification product 202 to the other end of the sameamplification product 202. With both types of ligation products (204 and206), the mecA gene is brought into close physical proximity with S.aureus genetic material (e.g. attR, orfX). Accordingly, both types ofligation products are suitable templates for nucleic acid amplificationmethods which are most effective at amplification of relatively smallamplicons (e.g. 2000 nucleotides or less). Thus, the next step of amethod provided herein involves using the ligation products for a secondnucleic acid amplification step. This second nucleic acid amplificationstep will use at least a first primer which anneals to a portion of themecA gene (or optionally, another portion of the SCCmec cassett), and asecond primer which anneals to S. aureus genetic material. Variousnucleic acid amplification methods may be used for the second nucleicacid amplification step, such as PCR or an amplification method asdescribed in PCT/US14/56151, filed Sep. 17, 2014, which is herebyincorporated by reference in its entirety for all purposes. Inembodiments, the first primer and second primer of the second nucleicacid amplification step are different than the first primer and secondprimer of the first nucleic acid amplification step (which producedproduct 202). In embodiments, the first primer and second primer of thesecond nucleic acid amplification step have an opposite orientation ascompared to the first primer and second primer of the first nucleic acidamplification step. In embodiments, the first primer and second primerof the second nucleic acid amplification step are the same as the firstprimer and second primer of the first nucleic acid amplification step.

FIG. 6 provides exemplary primer sequences which may be used with amethod provided herein.

In embodiments, all of the steps of methods provided herein may bepermitted to occur simultaneously in the same vessel (e.g. all reagentsfor methods provided herein may be provided in the same vessel at thesame time).

In addition to being used for the detection of true MRSA bacteria, themethod provided herein may also be used for the detection of othergenetic elements in other species or molecules, in which, for example,there are two or more genetic elements which may be on a common nucleicacid strand or part of a common molecule, but for which the elements areseparated from each other by a large nucleotide distance. The generalapproach as provided herein (i.e. to perform a first amplificationreaction, followed by a ligation reaction, followed by a secondamplification reaction) may be used for a wide range of genetic elementswhich present a similar structural problem.

In addition, in embodiments, the first amplification reaction providedherein may be omitted, if multiple copies of a molecule containinggenetic elements of interest are already present, and such molecules maybe ligated together to form structures in which the elements of interestmay be readily amplified by, for example, as PCR or an amplificationmethod as described in PCT/US14/56151.

Example 4 SNP Detection

Within Hepatitis C genotype 1a, there is a polymorphic site Q80K in theprotease gene, NS3, that is associated with treatment failure with theprotease inhibitor boceprevir, which otherwise can be effective inblocking peptide maturation in the virus. Assessing the Q80 polymorphismin the NS3 gene in patients with subtype 1a can be an important part offormulating a treatment plan.

Accordingly, improved reagents and methods for assessing the Q80polymorphism are needed. In addition, improved reagents and methods forassessing other SNPs are needed.

Provided herein are systems and methods for assessing SNPs. Variousfeatures described herein may be applied to any of the particularembodiments set forth below or for any other types systems for orinvolving assessing SNPs. Systems and methods described herein may beapplied as a standalone system or method, or as part of an integratedsystem or method. It shall be understood that different aspects of thedisclosed systems and methods can be appreciated individually,collectively, or in combination with each other.

In embodiments, provided herein are compositions and methods forevaluating a SNP, mutation, or other nucleotide of interest in a targetsequence. In some situations, a target sequence may have multipledifferent polymorphisms which surround the position of the nucleotide ofinterest. For example, the nucleotide of interest may be located in the60^(th) nucleotide position of a target sequence of 150 nucleotides(with the 5′ most nucleotide being in the first position, the nucleotidenext to the 5′ most nucleotide being in the second position, etc.).

In embodiments, a nucleotide of interest may be evaluated through use ofa method for SNP detection as provided in PCT/US14/56151, filed Sep. 17,2014, which is hereby incorporated by reference in its entirety for allpurposes. In such a method, a primer pair is used to amplify a targetnucleic acid containing the nucleotide of interest, wherein each primercontains a tail/first region and a template-binding/second region. Inembodiments, the tail of the/first region of the second primer of theprimer pair is complementary to a portion of the target nucleic acidincluding the nucleotide of interest. In a method as disclosed inPCT/US14/56151, the identity of a nucleotide of interest may bedetermined, for example, by comparing the rate or amount ofamplification of a target nucleic acid containing the nucleotide ofinterest by one or more primer pairs having slightly differentnucleotide sequences in the first/tail region of the primer (typicallyby just a single nucleotide difference between the primer pairs).

However, in some situations, it may be difficult to perform a method forSNP detection as provided in PCT/US14/56151, if there is a lot ofsequence variance in the target nucleic acid one or more positions nearthe nucleotide of interest. Such positions, for example, may be in theregion corresponding to the template-binding regions of the first and/orsecond primer. If the primers as described in PCT/US14/56151 for SNPdetection are not able to readily bind to a target nucleic acidsequence, the method disclosed therein may not be effective for SNPdetection.

Accordingly, provided herein are compositions and methods whichfacilitate the identification of SNPs. In a first step, a region of atarget nucleic acid containing the nucleotide of interest is amplifiedby a first amplification reaction (such as PCR), to generate a firstamplification product. In this first amplification reaction, relativelylong primer pairs (e.g. each primer contains at least 15, 20, 25, 30,35, 40, 45, 50, 55, 60, 65, 70, 80, 90, or 100 nucleotides) are used toamplify the target nucleic acid. The long primers may toleraterelatively large amounts of sequence diversity in the template-bindingregions (i.e. because the primers are long, they may still anneal to atarget sequence, even if multiple nucleotides are mis-matched).Importantly, in the first amplification reaction, neither of the primersis to anneal to the exact position of the nucleotide/SNP of interest(i.e. the primers should only anneal to areas near the SNP of interest).This is because with methods provided herein, it is not desirable tochange the identity of the nucleotide/SNP of interest (since it isdesired to identify the nucleotide/SNP of interest). Once a firstamplification product is generated in the first amplification reaction,the first amplification product will have a generally known nucleotidesequence (as a result of knowing the nucleotide sequence of the primersused in the first amplification reaction to generate the firstamplification product). However, the identity of the nucleotide/SNP ofinterest will still be unknown in the first amplification product, sinceneither of the primers used in the first amplification reaction annealedto the location of the nucleotide/SNP of interest. The firstamplification product may then incubated with primers as provided inPCT/US14/56151 for SNP detection. These primers may be designed to haveregions that are complementary to sequences that are known to be presentin the first amplification product, based on the fact that the firstamplification product was generated through use of primers of knownsequences. The identity of a SNP/nucleotide of interest may then bedetermined as described in PCT/US14/56151.

FIG. 7 provides a general schematic of a method provided herein. Anucleic acid strand 100 containing a target nucleic acid 102 may beprovided. The target nucleic acid 102 may contain multiplepolymorphisms/variant nucleotides 104. The target nucleic acid 102 alsocontains a nucleotide/SNP of interest 106. The target nucleic acid isincubated with a first primer 112 and second 114 primer, in order togenerate a first amplification product 120. The first amplificationproduct 120 will have a generally known nucleotide sequence, since itwas amplified with the first primer 112 and second primer 114 (whichhave known nucleotide sequences). During the process of generating thefirst amplification product 120, the multiple polymorphisms/variantnucleotides 104 are replaced by the nucleotides of the first primer 112and second primer 114. However, the first amplification product 120still has an unknown nucleotide/SNP of interest 106. The firstamplification product 120 may then be used in a method as described inPCT/US14/56151 for SNP detection.

In embodiments, methods provided herein may be used to assess a SNP inthe polymorphic site Q80K in the Hepatitis C protease gene, NS3. FIG. 8provides exemplary primer sequences which may be used as part of amethod for assessing the Q80K site. Methods provided herein may be usedto assess SNPs in many different target nucleic acids, wherein thetarget nucleic acids have a high level of sequence variability.

FIG. 9 provides results from steps of a method performed as describedherein. FIG. 10 provides primer sequences used for the experiments ofFIG. 9. In addition, nucleotide sequences also used for the results ofFIG. 9 were as follows:

T255Q sequence:

SEQ ID NO: 5) GGAACGAGGACCATCGCATCACCCAAGGGTCCTGTTATCCAGATGTATACCAATGTAGACCAAGACCTCGTGGGCTGGCCCGCTCCTCAAGGTGCCCGCTCA TTGACACCCTGCACCTGCG.

T255K sequence:

(SEQ ID NO: 6) GGAACGAGGACCATCGCATCACCCAAGGGTCCTGTTATCCAGATGTATACCAATGTAGACAAAGACCTCGTGGGCTGGCCCGCTCCTCAAGGTGCCCGCTCA TTGACACCCTGCACCTGCG

In embodiments, all of the steps of methods provided herein may bepermitted to occur simultaneously in the same vessel (e.g. all reagentsfor methods provided herein may be provided in the same vessel at thesame time).

Example 5 Zika Virus Detection

Zika virus (ZIKV) has received global scrutiny following an outbreak inSouth America, causing a spectrum of neurologic complications includingmicrocephaly. Current ZIKV diagnostic procedures begin with initialobservation of clinical symptoms, including any combination of fever,conjunctivitis, and rash. The range of ZIKV RNA concentrations in seraof symptomatic patients is about 900 to about 729,000 copies/mL, asdetected by rRT-PCR (Lanciotti, et al., Emerg Infect Dis. 2008;14(8):1232-1239). ZIKV rRT-PCR dan also detect ZIKV in urine and salivafor up to two additional weeks after ZIKV becomes undetectable in blood(Zhang, et al., Lancet Infect Dis. 2016; 16(6):641-642; Barzon, et al.,Euro Surveill. 2016; 21(10)).

This Example provides a ZIKV nucleic acid amplification test (ZNAT) thatdetects ZIKV RNA in capillary EDTA whole blood (CWB) samples and venousserum samples.

Methods: The Zika nucleic acid amplification test system (ZNAT) usesnested primers in two sequential reactions that comprise RT-PCRamplification followed by isothermal amplification and detection. Thistest is performed using a single-use cartridge that is processed on afully automated, transportable device (an automated, diagnosticplatform) with fully integrated sample preparation and processingcapabilities. The test system can process and amplify nucleic acid fromvenous serum or capillary whole blood, requires minimal handling, and iscomplete in about 2 hours. The analytical performance of the ZNAT wascompared to the Centers for Disease Control and Prevention (CDC) andaltona Diagnostics Zika RT-PCR tests (altona assay) using serum andcapillary whole blood (CWB) samples from the Dominican Republic,Colombia, and United States, including from symptomatic and pregnantsubjects.

Results: The ZNAT had analytical sensitivities of 320 and 480 genomiccopies/mL for capillary whole blood and serum, respectively. The ZNATdetected multiple Zika strains, including the current South AmericanPRVABC59 strain and two African strains. The test did not cross-reactwith other flaviviruses or pathogens that produce Zika-like symptoms.The ZNAT successfully detected Zika virus in both venous serum andcapillary blood of symptomatic patients from the Dominican Republic andColombia. When compared to results from both the CDC Zika RT-PCR andaltona Diagnostics RealStar® assays, ZNAT exhibited 100% sensitivity (67of 67 samples [95% CI 94.6-100]) with 95.6% specificity (109 of 114samples [95% confidence interval (CI) 90.1-98.6]) for serum samples and98.0% sensitivity (50 of 51 samples [95% CI 89.7-99.7]) and 100.0%specificity (56 of 56 samples [95% CI 93.6-100.0]) for capillary wholeblood samples.

The ZNAT performance is equivalent to existing Zika diagnostics. Theseresults demonstrate that ZNAT can provide rapid and accurate results andcan provide efficient diagnostic testing in regions of immediate needwithout requiring the presence or intervention of molecular-biologytrained technicians. The combination of capillary collection andshipping technology with low cost nucleic acid analysis facilitateseffective screening in remote locations otherwise difficult to access.

Materials and Methods

ZNAT workflow: Disposable, barcoded test cartridges contained allnecessary assay reagents and consumables. Sample collection units (SCUs,Theranos, Palo Alto, Calif.) containing CWB or serum were inserted intotest cartridges (see next section) and the cartridges were inserted intothe sample processing unit (SPU), which is an automated sample analysisdevice. The fully automated SPU processed blood samples for RNAextraction and nucleic acid amplification. Reagents and consumables usedfor the test were returned back into the cartridge upon assaycompletion; the assay cartridge was then ejected and retrieved bytrained personnel and disposed of as bio-hazardous waste. The run timefor analysis (e.g., from time of sample insertion into the automatedsample analysis device to the analytical result was approximately 2hours.

Specimen collection: Venous blood was collected using standardprocedures into serum separator tubes (BD Biosciences #367987, FranklinLakes, N.J.) by trained phlebotomists and then centrifuges at 1300×g for15 minutes. Capillary whole blood (CWB) was collected after fingerstickswith disposable lancets (BD Biosciences #366593, Franklin Lakes, N.J.),and with EDTA-coated Sample Collection Devices (SCDs) (Theranos, PaloAlto, Calif.); SCDs contained detachable SCUs. Serum was obtained from102 symptomatic subjects from the Dominican Republic (D.R.) and Colombia(Boca Biolistics, Pompano Beach, Fla.; Allied Research Society, MiamiLakes, Fla.). Matched subject CWB, serum, and urine samples wereobtained from 30 subjects from the D.R (Boca Biolistics, Pompano Beach,Fla.). Serum samples from 25 febrile U.S. patients were obtained fromcommercial vendors (Access Biologicals LLC, Vista, Calif.). 78 serum and77 CWB samples were obtained from Zika-asymptomatic U.S. volunteers. Allsamples were collected after written, informed consent with approvalfrom an ethics committee.

ZNAT assay workflow: All necessary assay reagents and consumables wereassembled in disposable, barcoded assay cartridges. SCUs containingserum or capillary whole blood were inserted into assay cartridges (seenext section) and the cartridges were inserted into the SPU. Thesample-to-result fully-automated SPU extracted RNA from samples andperformed nucleic acid amplification. Reagents and consumables used forthe assay were returned back into the cartridge upon assay completion;the assay cartridge was then ejected and disposed of as bio-hazardouswaste.

Blood sample preparation for ZNAT: Each SCU, comprised of two identicalstorage vessels, contained a total of 160 μL of CWB or serum. Asnecessary, live ZIKV (strain PRVABC59, Centers for Disease Control,Atlanta, Ga.) was added into CWB or serum blood samples. ZIKV was addedmanually for serum samples or automatically within SPUs for CWB samples.The SPU also added MS2 bacteriophage to the serum and CWB samples toserve as a positive control for sample preparation/RNA extraction andthermal cycling-based amplification.

For CWB samples with added ZIKV, ZIKV stocks at 27.7× the desiredconcentration, diluted in Tris-EDTA (TE) buffer pH 8.0 (IDT DNA,Coralville, Iowa) with 1 U/μL of RNase-inhibitor (Thermos, Palo Alto,Calif.), were manually pipetted into a specified vessel within the ZNATcartridge before insertion into a SPU. Within the SPU, the device spiked3 μL of 27.7×ZIKV stock into each of the two vessels of the SCU, witheach containing approximately 80 μL of CWB to yield a 1:27.7 dilution.For venous serum samples with added ZIKV, live ZIKV was diluted withserum matrix and then manually pipetted to yield the desired, finalconcentration. 80 μL of venous serum with added ZIKV was then manuallydispensed into each vessel of an SCU, placed into a ZNAT cartridge.

SPU operation and functionality: SPUs were equipped with all necessarymechanical and software components to process ZNAT assay cartridges,including the ability to automate the ZIKV RNA extraction, nucleic acidamplification, and detection processes. These components include anautomated, multi-channel liquid handling system, centrifuge,thermal-cycler, 64-well isothermal heat block with an optical sensor anddetector laser-emitting diode per well, and network functionality. SPUswere completely enclosed instruments except for a retractable cartridgeinsertion door and filtered intake/exhaust vents. SPUs were controlledthrough a touch-screen user interface and were remotely monitored usinga secured network connection. ZIKV diagnostic results were transmittedto secured, encrypted, remote servers, collectively known as theTheranos Laboratory Automation System (TLAS), and data retrieved bytrained personnel.

Automated RNA extraction from blood samples: Both serum and CWB sampleswere first centrifuged and then serum and plasma, respectively, weresubjected to lysis, RNA capture onto magnetic beads, washing, and thenRNA elution into water.

The SPU added MS2 bacteriophage positive control (Theranos, Palo Alto,Calif.), lithium chloride (Sigma-Aldrich, St. Louis, Mo.), andiodoacetic acid (Santa Cruz Biotechnology, Santa Cruz, Calif.) to bloodor serum samples to yield final concentrations of 18.75 plaque-formingunits (PFU)/mL, 300 mM, and 150 mM, respectively. Both lithium chlorideand iodoacetic acid served as RNase inhibitors. Samples were centrifugedon board the SPU at 1,448 RCF (relative centrifugal force) for 4 min,and 75 μL of supernatant (e.g. plasma in the case of whole bloodsamples) underwent RNA extraction. Both ZIKV and MS2 bacteriophage inplasma or serum were lysed for 5 min in 450 μL of RNA-extractionlysis/binding buffer (Thermo Fisher, Waltham, Mass.) with 36 μMbeta-mercaptoethanol (βME), followed by RNA capture via incubation with30 μL magnetic beads (Zymo Research, Irvine, Calif.). Beads werecaptured with a sleeved, magnetic rod and washed in commercial,proprietary wash buffers: 225 μL of wash-1 buffer for 3 min, and 225 μLof wash-2 buffer for 3 min (Thermo Fisher, Waltham Mass.). ZIKV and MS2RNAs from the magnetic beads were eluted in 50 μL DNase/RNase-free water(Teknova, Hollister, Calif.).

MS2 phage preparation: C3000 bacteria was grown in #271-L media (LuriaBertani medium containing 2% glucose, 53 mM CaCl₂, and 0.02% thiamine(vitamin B12) and infected with MS2 bacteriophage (ATCC #15597-B1™,Manassas, Va.) over #271 soft agar media using standard procedures.After 18 h, soft agar media harboring bacteria and phage particles wascollected and passed through a 0.2 μm filter. MS2 phage particles werepurified through precipitation with 4% PEG8000 and 0.5 M NaCl. MS2 phageparticles were pelleted by centrifugation at 6,500×g, followed byresuspension in TMSG buffer (10 mM Tris pH 7.5, 100 mM NaCl, 1 mM MgCl₂,0.1% gelatin, 0.05% NaN₃) and storage at 4° C.

Automated preliminary amplification: The liquid handling system withinthe SPU added 40 μL of extracted RNA to 60 μL of preliminaryamplification master mix. Template-negative, DNase/RNase-free water wasused in a separate parallel reaction as a negative control. Reactionvessels were overlaid with mineral oil (Sigma, St. Louis, Mo.) andtransferred by the sample handling system of the SPU to athermal-cycling module in the SPU to commence RT-PCR.

The preliminary amplification mix yielded final concentrations of 1×Phusion High-Fidelity buffer (New England Biolabs #B0518S, Ipswich,Mass.), 0.25 mM dNTP, 0.975 mM MgCl₂, 0.008 mg/mL reverse-transcriptase(RT, Theranos, Palo Alto, Calif.), 1.25 mg/mL DNA polymerase (D-Pol,Theranos, Palo Alto, Calif.), 0.8 μM of each pre-amp primer againstZIKV, and 0.8 μM of each pre-amp primer against MS2 phage.Thermal-cycling parameters started with 42° C. for 3 min for the reversetranscription reactions. Preliminary amplification utilized one cycle ofa denaturation step at 94° C. for 84 sec, annealing step at 62° C. for33 seconds, extension step at 72° C. for 32 seconds followed by 30cycles of 94° C. for 5 seconds, 62° C. for 15 seconds and 72° C. for 8seconds.

Automated isothermal amplification and detection: Primer pairs containedpair-wise complementary 5′ ends that resulted in amplicons containing 5′overhangs. These overhangs facilitated the generation of fluorescentlydetectable concatemers. Three μL of pre-amplified product (see above)for both sample and negative control were added by the automated liquidhandling system into separate wells containing 22 μL of isothermalreaction mix against ZIKV or MS2. ZIKV DNA target amplicon, at 1×10⁶copies/mL, was used as an isothermal-specific positive control in aseparate well. Assays were invalid if any controls failed (see FIG. 11B,which presents a Table for ZNAT results interpretation).

Isothermal reaction mixes contained a final concentration of 0.64%Tween®-20 (Sigma, St. Louis, Mo.), 160 mM Tris-HCl pH 7.9 (Teknova,Hollister, Calif.), 80 mM Mg(CH₃COO)2 (Sigma, St. Louis, Mo.), 400 mMCH₃COOK (Sigma, St. Louis, Mo.), 8 mM dithiothreitol (DTT) (Teknova,Hollister, Calif.), 400 mM betaine (Sigma, St. Louis, Mo.), 2 μMSYTO®-59 (Thermo Fisher, Waltham, Mass.), 1.6 mM dNTP mix (Sigma, St.Louis, Mo.), 0.097 μM Bst DNA polymerase (Theranos, Palo Alto, Calif.),and 1 μM each of forward and reverse primers (Theranos, Palo Alto,Calif.). Isothermal reactions were overlaid with a melted wax solutioncomprised of equal parts of 80% isododecane mixture (Alfa Aesar, WardHill, Mass.) and melted paraffin wax (Sigma, St. Louis, Mo.) thatsolidified at room temperature (approximately 22° C.) but melted into anoptically-clear liquid after 1 min at 56° C. The isothermal reaction isconducted at 56° C. during which SYTO®-59 relative fluorescence unit(RFU) measurements were taken every minute for 35 minutes within theisothermal module of the SPU. Inflection time calculations weredetermined from sets of four consecutive time points (t₀, t₁, t₂, t₃).If the difference in signal (As) between adjacent time points within aset of time points were greater than a pre-defined threshold, then towas determined as the inflection time.

Zika target sequence for ZNAT: A 101 base-pair region within the Zikapolyprotein gene was selected as the target sequence using in-housesoftware algorithms and multiple sequence alignments of available Zikapolyprotein gene sequences. This target sequence includes:

(SEQ ID NO: 7) AAGCCTACCTTGACAAGCAATCAGACACTCAATATGTCTGCAAAAGAACGTTAGTGGACAGAGGCTGGGGAAATGGATGTGGACTTTTTGGCAAAGGGAGC

Notably, this target sequence is present in the genome of Zika strainsin the current Brazilian outbreak (e.g. GenBank accession #KU991811,b.p. 1179-1239).

Primers for ZNAT: Two pairs of primers were designed and synthesized denovo (Thermos, Palo Alto, Calif.) for each target sequence, where onepair was used for preliminary amplification (pre-amplification) viathermocycling and another pair was used for isothermal amplification anddetection. Pre-amplification primer pairs were chosen according to theirperformance at an annealing temperature of 61.5° C. and screened fromseveral primer pairs suggested by in-house software according to giventarget sequence inputs. Potential isothermal primer pairs were chosen byscreening >100 possible primer pairs as suggested by proprietarysoftware, which also determines the most appropriate tail-ends of eachprimer. Primers were further narrowed down by their specificity inamplifying only the target sequence within human genomic backgroundswithout amplifying any target-independent products. The followingprimers were used:

Pre-Amplification:

Zika Forward: (SEQ ID NO: 8) 5′-AAGCCTACCTTGACAAGC-3′ Zika Reverse:(SEQ ID NO: 9) 5′-GCTCCCTTTGCCAAAAAG-3′ MS2 phage Forward:(SEQ ID NO: 10) 5′-ACCAGCATCCGTAGCCTTATT-3′ MS2 phage Reverse:(SEQ ID NO: 11) 5′-GGACCGCGTGTCTGATCC-3′

Isothermal Amplification and Detection:

Zika Forward: (SEQ ID NO: 12) 5′-TTTCCCCATCAGACACTCAATATGT-3′Zika Reverse: (SEQ ID NO: 13) 5′-TGGGGAAAGCCAAAAAGTCCACA-3′MS2 phage Forward: (SEQ ID NO: 14) 5′-GTGCCCCAGTTCTCCAACGG-3′MS2 phage Reverse: (SEQ ID NO: 15) 5′-TGGGGCACTTGTAAGGCGCTGC-3′

In-silico analysis of Zika pre-amplification and isothermal primers:Primer-BLAST (NIH NCBI) was employed as previously published, utilizingthe publically available “nr” nucleotide sequence database (Ye J,Coulouris G, Zaretskaya I, Cutcutache I, Rozen S, Madden T L.Primer-BLAST: a tool to design target-specific primers for polymerasechain reaction. BMC Bioinformatics. 2016; 13: 134; Yoshida A, NagashimaS, Ansai T, Tachibana M, Kato H, Watari H, et al. Loop-mediatedisothermal amplification method for rapid detection of theperiodontopathic bacteria Porphyromonas gingivalis, Tannerellaforsythia, and Treponema denticola. J Clin Microbiol. 2005; 43(5):2418-24). Cross reactivity against each organism was tested explicitlyby entering its taxonomy id. Primers with six or more mismatches wereconstituted as non-reactive. Furthermore, OligoAnalyzer 3.1 (IDT) wasused to estimate the decrease in Tm due to mismatches at specific sites.To get a lower bound estimate of the effect of six mismatches, we tookthe mutation with the smallest influence on Tm at each site, and thensorted by Tm change. The sum of the ΔTm for the 6 mutations with theleast effect was 15.1° C., at which point we anticipate <1% of theoligonucleotides to be annealed to a target with these six mismatches atthe temperature and conditions of the isothermal reaction.

Analytical sensitivity study: The analytical sensitivity studydetermined the limit of detection (LoD) of ZNAT based on inflectiontime. The cut-off for the inflection time was defined as the time before≥95% of the NTC (no template control) inflections occurred while alsobeing after ≥90% of the inflection times for ZIKV samples at 1× thelimit of detection (LoD). A total of 33 replicates of positive Zikasamples at 320 copies/mL (10 PFU/mL) (1× Limit of Detection (LoD) basedon the preliminary LoD of 10 PFU/mL) and 40 false positive ZIKVinflections from negative controls among greater than 1,500 assay runswere compiled and considered during determination of the cut-off time.The limit of detection was deemed the lowest viral concentration levelcorresponding to a detection rate of 95%. Inflections were consideredpositive as long as they occurred before the cut-off time; the lowestconcentration displaying a 100% ZIKV detection rate from at least sixreplicates was further evaluated by precision testing with 20 or moreadditional test replicates. Standard qRT-PCR methods with SYBR™ GreenMaster Mix (Thermo Fisher Scientific #4367659, Waltham Mass.) and denovo synthesized ZIKV gene standards were used to determine a conversionfactor from PFU/mL to copies/mL (1 PFU=32.6 copies) for the PRVABC59strain.

Inclusivity: Two commercially available ZIKV strains, DakArdD 41662 andMR 766 (Zeptometrix, Buffalo, N.Y.), were tested in ZNAT using SPUs;using the CDC Zika RT-PCR methods; and using an in-house Zika RT-PCRassay at a concentration of 2×LoD in serum.

Analytical specificity: A total of 11 pathogens were tested forcross-reactivity based on their taxonomic position (other members of thegenus Flavivirus with high sequence homology to ZIKV) and prevalence inSouth America, including pathogens causing diseases with symptoms suchas fever, conjunctivitis, and rash. The 11 pathogens and nine potentialinterfering substances found in blood were tested in triplicate, addedinto serum with or without added ZIKV at 2×LoD. Potential bloodinterfering substances were diluted in their respective diluents andstored at 10× the tested concentration with the exception of thetriglyceride mix. The triglyceride mix was stored as a 70× stock becausefurther dilution would require the solvent methanol, which inhibits theZNAT. The interfering substance stocks were diluted 1:10, or 1:70 forthe triglyceride mix, into serum when generating the serum samples fortesting.

Nucleic acids were either extracted from cultured viral stocks obtainedfrom commercial vendors or used as inactivated virus. Cross-reactantswere added to specific vessel in the cartridge, which then wereautomatically added into the lysis/binding reaction within SPUs atvarious concentrations. For 10× and 70× stock preparations, thefollowing interfering substances were diluted as: bilirubin in DMSO;cholesterol in ethanol, gamma globulin in 0.9% NaCl, and human genomicDNA (hgDNA) in TE buffer pH 8.0 (IDT DNA, Coralville, Iowa), and allother potential interfering substances were diluted in DNase/RNase-freewater (Teknova, Hollister, Calif.). The substances bilirubin,cholesterol, gamma-globulin, hemoglobin, hgDNA, and triglycerides, werechosen because they are components of human blood and have the potentialto interfere with the assay if they are not removed by the sample prepprocess. The substances EDTA, heparin lithium salt, and sodium citrateare common anti-coagulants used when collecting blood samples. Allsubstance test concentrations, with the exception of the anticoagulants,were recommended by the Clinical Laboratory Standards Institute (CLSI)guideline EP7-A2: Interference Testing Clinical Chemistry. Ten virusesand one parasite tested for analytical specificity were obtained fromZeptometrics and ATCC and all interfering substances we obtained fromSigma-Aldrich. The nucleic acids of nine viruses (excluding parvovirus)and one parasite were extracted from cultured material obtained fromvendors using the QIAcube® automated sample prep device using the QIAGENQIAamp Viral Mini Kit (Qiagen, Hilden, Germany). The purified nucleicacids were quantified through qRT-PCR. Serial ten-fold dilutions of asynthetic RNA or DNA template of known concentration was used to preparestandards for qRT-PCR. Each of the lysates were diluted 10, 100, and1000 fold from respective stocks. Purified samples were tested inparallel with the standards. Ten-fold serial dilutions of synthetic RNAstandards determined a standard curve. Lysates concentrations weredetermined by extrapolating the concentration values in copies/mL fromthe standard curve.

CDC RT-PCR assay: Based on the protocol provided by CDC (TaqMan RealTime RT-PCR Protocol—25 μL), several modifications were made by CDC tothe previously published methods by Lanciotti et al. These include theusage of 5 μL of RNA extract instead of 10 μL. Each of the two assayswithin the CDC RT-PCR test utilized two separate sets of primers andprobes. Each assay utilized RNA extracted from the same blood specimenwithin two test wells per assay. Positive ZIKV test results were definedby all four test wells yielding Ct values <38. The CDC Zika RT-PCRprotocol notes that their test includes two primer/probe sets for thedetection of Zika virus RNA. The first set detects all known genotypesof Zika virus; the second, modified set Zika4481/4507cFAM/4552c isspecific for Zika virus Asian genotype currently circulating in theWestern Hemisphere and is specified below:

Zika4481 (SEQ ID NO: 16) CTGTGGCATGAACCCAATAG Zika4507cFAM(SEQ ID NO: 17) CCACGCTCCAGCTGCAAAGG Zika4552c (SEQ ID NO: 18)ATCCCATAGAGCACCACTCC

Statistical Analyses: 95% confidence intervals (CIs) on PPA and NPA werecomputed according to equations 15 & 15B under section 10.2.2 in CLSIEP12 A2E guidelines.

In-house Zika rRT-PCR assay: Serum samples were processed according tomanufacturer's instructions using the QIAcube workstation (Qiagen,Valencia, Calif.). RT-PCR reactions were prepared by adding 1×qPCR AssayQuantiTect Probe RT-PCR master-mix (Qiagen, Valencia, Calif.), 1 μM Zikaforward primer (GACATGGCTTCGGACAG (SEQ ID NO: 19)), 1 μM Zika reverseprimer (ATATTGAGTGTCTGATTGCTTG (SEQ ID NO: 20)), 0.15 μM Zika probe (5′FAM TGCCCAACACAAGGTGAAGCC Dabcyl 3′ (SEQ ID NO: 21)), 0.25 μM enzyme mix(Qiagen, Valencia, Calif.), 5 μL template. Reactions were run using thefollowing thermocycling program, and monitored in the FAM channel:Reverse transcription step at 50° C. for 30 min, denaturation at 95° C.for 15 sec, followed by 45 cycles of 95° C. for 15 sec, 60° C. for 1 minon the Bio Rad CFX96 Touch™ Real Time PCR Detection System (Bio Rad,Hercules, Calif.).

Run-to-run (Carry-over) contamination assessment for ZNAT: Tenconsecutive runs were performed on each of five SPUs, where each runalternated between serum samples with ZIKV at 1.3×10⁷ genomic copies/mLor without ZIKV.

Clinical study: ZIKV detection rates in blood samples obtained fromColombia, Dominican Republic, and U.S., including from Zika-symptomaticsubjects, were compared between the ZNAT and CDC ZIKV RT-PCR assay.Discordant results between the two assays were further tested with thealtona Diagnostics GmbH RealStar® Zika Virus RT-PCR (“altona DiagnosticsRealStar®”) method (altona Diagnostics, Hamburg, Germany). CDC ZIKVRT-PCR was performed following a modified CDC protocol using serum(Lanciotti R S, Kosoy O L, Laven J J, Velez J O, Lambert A J, Johnson AJ, et al. Genetic and serologic properties of Zika virus associated withan epidemic, Yap State, Micronesia, 2007. Emerg Infect Dis. 2008; 14(8):1232-9). The altona Diagnostics RealStar® assay was performed as permanufacturer protocol, using serum or urine. ZIKV RNA extraction wasperformed on the Qiacube automated device (Qiagen, Hilden, Germany).Thermal-cycling and fluorescent detection was performed on the Bio-RadC1000 Touch™ with CFX96™ Optical Reaction Module (Bio-Rad, Hercules,Calif.).

Results

Analytical sensitivity of ZNAT: The cut-off time of the assay wasdetermined to be the time point before which any inflection was deemed apositive test result (i.e. ZIKV inflection). ZIKV inflection times <40min were obtained from both true- and false-positives. True-positivescomprised 27 serum samples with ZIKV added at 1× of the preliminary LoDwhile 40 false-positives were collected from >1,500 preliminary testassays. All ZIKV inflections were plotted as a histogram (FIG. 11A). Thehistogram shown in FIG. 11A is a histogram plot for Cut-offdetermination for ZNAT, showing a histogram of ZIKV inflections <40minutes from totals of 40 and 27 venous serum samples, with added ZIKVat 10 plaque-forming units (PFU)/ml (1×LoD (LoD=limit of detection)) orwithout ZIKV (no template control (NTC)). Receiver operatingcharacteristic (ROC) curve analyses identified 27.0 min as a cut-offtime allowing >90% sensitivity (true-positive detection rate) and >95%specificity (true-negatives exclusion rate) in serum samples (FIG. 11A).

ZNAT analytical sensitivity was determined by ZIKV (strain PRVABC59 fromthe CDC) at various concentrations in serum, including 0, 1, 5, 15, 30,and 60 PFU/mL with equivalent genomic copies of 0, 32, 160, 480, 960,and 1920 copies/mL respectively at n=6 replicates each. 15 PFU/mL (480copies/mL) was the lowest concentration in serum at which 100% of theresults were positive and was further confirmed as the final LoD when ityielded a 95% ZIKV detection rate for 20 additional replicates (FIG. 13,showing analytical sensitivity determination of ZNAT). This method wassimilarly applied to CWB, which established 10 PFU/mL (320 copies/mL) asthe final LoD for yielding 95% positive ZIKV detection rate for 20replicates (FIG. 13). Taking initial viral titers into consideration,qRT-PCR determined that 10 and 15 PFU/mL corresponded to approximately327 and 490 copies/mL, respectively (FIG. 12, showing quantification ofthree ZIKV lysates). As shown in FIG. 12, qRT-PCR was used to convertplaque-forming units (PFU) and half-maximal tissue culture infectivedose (TCID₅₀) values to number of copies for three different ZIKVlysates. Ten-fold serial dilutions of synthetic RNA standards (indicatedby circles) were used to determine a standard curve. Lysates of unknownconcentrations tested in parallel are indicated by crosses.

Inclusivity of ZNAT: In silico analyses were conducted using 109sequences from 38 publicly available (as of Jun. 1, 2016) ZIKV strainsto determine whether ZNAT PCR primer pairs contained complementarysequences. Complete complementation was observed for 31 strains,suggesting that the ZNAT primers should detect these ZIKV strains. Theremaining seven strains exhibited at least one base pair mismatch withinthe primer binding sites, indicating these strains may have decreaseddetection rates due to incomplete primer-target DNA binding (FIG. 14, atable showing the results of in silico analyses of ZNAT primers againstsequenced Zika virus strains). Two of these seven strains, ArD157995 andMR 766, possessed at least two base pair mismatches within primerbinding sites (FIG. 14). Of these two mismatch-containing strains, onlyMR 766 was commercially available to test ZNAT. ZNAT successfullydetected both MR 766 and another commercial strain that did not containany mismatches, DakArD 41662, at 960 copies/mL, in serum samples. Incontrast, the CDC ZIKV RT-PCR assay failed to detect either strain inserum samples (FIG. 16). However, Theranos Zika RT-PCR primerssuccessfully detected both strains in the same RNA extracts that the CDCZika RT-PCR assay failed to detect, ruling out the possibility that theCDC Zika RT-PCR non-detections were due to faulty RNA extraction (FIG.15, showing, in Table form, reactivity/inclusivity analysis of ZNAT inserum). The concentrations tested for these two strains corresponded toapproximately 2× equivalents of the LoD for the CDC ZIKV (PRVABC59)strain, or 980 copies/mL (FIG. 12).

Analytical specificity of ZNAT: During primer design, in silico analysessuggested that cross-reactivity against large panels of pathogens withsimilar genetic sequences or ZIKV-like clinical symptoms was unlikelydue to the presence of multiple base pair mismatches between ZNATprimers and target priming sequences (FIG. 16 (a table showing in silicoanalysis of Zika preliminary amplification and isothermal primersagainst prevalent diseases with Zika-like onset symptoms) and FIG. 17 (atable showing in silico mismatch analysis of ZNAT primers againstpotentially cross-reacting organisms)). A panel of organisms bearingsignificant genetic homology or clinical similarity with ZIKV was testedusing ZNAT within serum samples. Tested organisms did not produce anyfalse results when tested using serum samples with or without 2×LoDZIKV, respectively (FIG. 18, a table showing results of cross-reactivityand interfering substance analyses of ZNAT in serum).

Interfering substances analysis of ZNAT: High concentrations of commoncomponents in whole blood, such as cholesterol or hemoglobin, canpotentially interfere with assays such as the ZNAT. These componentswere tested with added ZIKV at 0 or 30 PFU/mL (960 copies/mL) (0 or2×LoD) in serum. No tested component contributed any observable changein ZIKV detection at 960 copies/mL (2×LoD), or any false positives at 0copies/mL (0×LoD) of ZIKV (FIG. 19). In addition, the organismspreviously tested for cross-reactivity (above) did not produce any falsenegatives in samples containing 2×LoD ZIKV (FIG. 19).

Run-to-run (carry-over) contamination analysis of ZNAT: To investigatewhether sample or amplicon contaminants carried over between consecutiveZNAT device tests, five SPU devices were used in five rounds of pairedZNAT assays. Each round of paired assays consisted of an initial assayof a sample containing high titer ZIKV (4×10⁵ PFU/mL, which is 1.3×10⁷copies/mL) followed by an assay of a sample lacking ZIKV (0 PFU/mL,which is 0 copies/mL), with all assays utilizing serum. Nofalse-positives were detected for any of the five SPU devices for any ofthe ZIKV-negative serum samples. This suggested that run-to-runcarry-over contamination did not occur, or was not significant (FIG. 20,a table showing the results of analyses of run-to-run contamination ofZNAT in serum).

Concordance studies: Serum samples were obtained from 78 U.S. subjectsand 102 Dominican Republic and Colombian subjects. Of the samplesobtained from Zika-endemic areas, 69 subjects were symptomatic patientswhose Zika status were unknown, and 33 were febrile subjects known to benegative on the CDC ZIKV RT-PCR assay. ZIKV was not detected by eitherthe ZNAT or the CDC assays in 78 serum samples from either healthy orfebrile subjects from the U.S., where ZIKV infections are currently rare(FIG. 21, a table showing the results of clinical studies using ZNAT).Of the 69 samples that were clinically unknown, the ZNAT detected ZIKVin samples from 39 of 69 subjects, whereas the CDC ZIKV RT-PCR assaydetected ZIKV in samples from 17 of 69 subjects (FIG. 21). Samples fromthe 22 discordant results that were ZNAT positive but CDC ZIKV RT-PCRassay negative were further tested with the FDA EUA-approved altonaDiagnostics RealStar® ZIKV RT-PCR assay. The altona Diagnostics assaydetected ZIKV in samples from 17 of the 22 discordant sample results(FIG. 21). Furthermore, to gauge the robustness of the ZNAT, the 33additional serum samples from febrile subjects collected in Colombia,that were first tested as ZIKV-negative by the CDC assay, were testedwith exogenously-added ZIKV at different concentrations. The CDC andZNAT assays yielded 100% ZIKV detection rates for all 33 samplescontaining exogenously added ZIKV at 480, 960, and 2400 copies/mL (15,30, and 75 PFU/mL) (FIG. 21).

To calculate the positive and negative percent agreement (PPA and NPA,respectively), test results from the combined CDC RT-PCR with altonaassays were used as the reference results. Therefore, the combined CDCRT-PCR and altona assays determined 67 total subjects to beZIKV-positive (CDC RT-PCR assay detected ZIKV in 17 of 69 subjects,altona confirmed an additional 17 subjects to be ZIKV-positive, and theCDC RT-PCR assay detected all 33 samples with exogenously added ZIKV).The Minilab ZNAA assay likewise detected ZIKV in the same 67 subjects orsamples. As the Minilab ZNAA assay detected ZIKV 39 of 69 subjects, fivemore than the combined CDC RT-PCR and altona assays, these five testresults were considered Minilab ZNAA false positives when calculatingNPA. When comparing the ZNAT to the CDC Zika RT-PCR assay withconfirmation of discrepancies by the altona Diagnostics assay, the ZNATdemonstrated 100% sensitivity (67 of 67 samples [95% CI 94.6-100]) with95.6% specificity (109 of 114 samples [95% CI 90.1-98.6]) for serumsamples (FIG. 21).

Concordance studies were also performed with CWB samples from 77 U.S.and 30 Dominican Republic subjects. As both CDC Zika RT-PCR and altonaDiagnostics assays were not cleared for use with capillary whole blood,matched-subject serum and urine specimens were obtained in addition tocapillary whole blood samples from Dominican Republic subjects.Specimens from 52 healthy, U.S. subjects tested ZIKV-negative by boththe ZNAT and CDC ZIKV RT-PCR assays (FIG. 21). Specimens from 25additional healthy, U.S. subjects were also prepared with added ZIKVwere tested on both the ZNAT and CDC Zika RT-PCR assays. The ZNATdetected ZIKV in 24 of 25 CWB samples with added ZIKV while the CDC ZikaRT-PCR assay detected ZIKV in 23 of 25 matched-subject serum samples(FIG. 21). The two samples with added ZIKV that tested ZIKV-positive byZNAT and ZIKV-negative by CDC RT-PCR testing were confirmed to beZIKV-positive by altona Diagnostics RealStar® testing (FIG. 21).

Additionally, the ZNAT detected ZIKV in 26 of 30 CWB samples fromDominican Republic subjects with Zika-like clinical symptoms while theCDC Zika RT-PCR assay detected ZIKV in only 5 of 30 matched-subjectserum samples (FIG. 21). Samples from all 21 discordant results wereconfirmed to be ZIKV-positive when using the altona Diagnostics assay oneither matched-subject serum or urine samples (FIG. 21). In 10 of these21 subjects, the altona Diagnostics assay did not detect ZIKV in theserum, but did detect ZIKV in the subject-matched urine samples. Thecombined CDC RT-PCR and altona assays determined 51 total subjects to beZIKV-positive (the CDC RT-PCR assay detected ZIKV in 5 DominicanRepublic subjects, altona confirmed an additional 21 Dominican Republicsubjects to be ZIKV-positive, and the CDC RT-PCR assay detected all 25samples with exogenously added ZIKV), while the Minilab ZNAA assaydetected ZIKV in all of the donor-matched capillary whole blood sampleswith the exception of one sample from a healthy subject with added ZIKV.When comparing the ZNAT to the CDC Zika RT-PCR assay with discordantsubject results confirmed by the altona Diagnostics assay, the ZNATdisplayed 98.0% sensitivity (50 of 51 samples [95% CI 89.7-99.7]) and100.0% specificity (56 of 56 samples [95% CI 93.5-100.0]) for CWBsamples.

Discussion

A novel sample-to-result diagnostic assay was developed to detect ZIKVin both venous serum and CWB samples. This assay was performed using asingle-use cartridge run on a transportable, fully-automated diagnosticplatform (the SPU). The analytical performance of the ZIKV assay wascharacterized in several studies. Namely, the assay performance was notaffected by high concentrations of common, potentially interferingsubstances, did not demonstrate cross-reactivity withgenetically-homologous or clinically-similar pathogens, detectedmultiple ZIKV strains, and showed no carry-over contamination from highviral load ZIKV samples. The assay had an LoD of 320 and 480 copies/mLfor CWB and serum, respectively. The ZNAT has a LoD that is at leastsimilar to the CDC ZIKV RT-PCR assay. Indeed, the ZNAT identified ZIKVin more symptomatic subjects from Zika-prevalent areas than did the CDCZIKV RT-PCR test. Of these 22 samples, 17 were subsequently confirmed asZIKV-positive using a third, FDA-approved, altona Diagnostics RealStar®ZIKV RT-PCR assay (FIG. 21). ZNAT also detected ZIKV in samples fromsymptomatic subjects that the altona Diagnostics assay failed to detectas having ZIKV, which suggests that ZNAT either has greater sensitivity,is more inclusive for Zlka strains, or has lower specificity than thealtona Diagnostics assay. However, the complete lack of false positiveresults among the serum and CWB samples collected from healthy orfebrile U.S. subjects and tested by ZNAT argues against a lack ofspecificity.

ZNAT detected ZIKV in capillary whole blood specimens from 21 subjectswhile the CDC ZIKV RT-PCR assay did not detect ZIKV in matched-subjectserum specimens from the same subjects. All 21 patients were confirmedZIKV-positive when their respective serum or urine samples were testedby the altona Diagnostics assay (FIG. 21). While ZNAT detected in these21 CWB specimens, the altona Diagnostics assay detected ZIKV in 11 of 21serum specimens. The altona Diagnostics assay only confirmed theremaining 10 patients to be ZIKV-positive when their urine specimenswere tested.

The present example demonstrates that the ZNAT can detect ZIKV in CWBwith sensitivities similar to serum, thereby obviating a need forvenipuncture. Implementing fingerstick phlebotomy to provide CWB samplesthat can be stably transported will aid in expanding ZIKV diagnostics,particularly in centralized testing locations and for pregnant women andneonates. Rapid ZIKV testing with increased accessibility can help womenbetter prepare for pregnancies and guide expectant mothers in managingtheir pregnancies. Combining protein-based or antibody-based, serologicZIKV tests in parallel with ZNAT diagnostics in the same platform maydistinguish active from cleared ZIKV infections.

FIG. 22—The Nucleic Acid Amplification based assays were run on thedetection system shown in this figure. This part of the module opens tocontain 64 discrete wells, capable of running 64 discrete reactionsincluding controls for a given assay. The thermocycler module is on thebottom left, and above it is an isothermal detector. The diagram on theright of FIG. 22 shows a cross-section of the isothermal detector. Thefluorescence based isothermal detector (shown at the upper left of thefigure) has dimensions of 2.5 inches high by 5.4 inches wide by 13.1inches long. The thermocycler module (shown at the lower left of thefigure) has dimensions of 3.9 inches high by 5.7 inches wide by 8.5inches long. There are series of sample vessels in the middle where thepath of the excitation LED can shine through the sample and be detectedas a fluorescent signal. Nucleic Acid Amplification-based assays may usea thermocycler module as shown on the bottom left of FIG. 22; afluorescence-based isothermal detection module is shown above thethermocycler module. The fluorescence-based isothermal detection moduleis capable of running 64 separate, distinct reactions, includingcontrols for a given assay.

A cross sectional diagram overview of the isothermal detector is shownon the right of FIG. 22. A series of sample vessels are shown in themiddle row where the light path of the excitation LEDs shines throughthe sample and then may be detected as a fluorescent signal by an arrayof photodetectors at the bottom. For the Zika assay, measurements aretaken every minute for 35 minutes in order to detect an inflection pointin the fluorescent signal. An image depicting an idealized plot offluorescence measurements taken periodically during the course ofmultiple thermal cycles is shown as an inset in FIG. 22.

FIG. 23A provides information regarding a novel isothermal nucleic acidamplification method for use with sample analysis devices and systems.In embodiments using automated sample analysis devices and systems asdisclosed herein, all of the sample prep may be automated and performedon board automated sample analysis devices using a magnetic bead basedextraction method performed using a sample handling systems or a fluidhandling system as disclosed herein. The amplification method is acombination of a thermal cycle based pre-amplification step, and then anisothermal amplification and detection step, according to methodsdisclosed herein. The high sensitivity is driven in part by a highlyefficient on-board sample extraction process. Primers were designedusing multisequence gene alignment.

The assay method employed by the automated assay device for the Zikaassay is an isothermal nucleic acid amplification method according tothe methods disclosed herein which requires 75 microliters of plasma orserum. All of the sample prep was automated on the automated assaydevice and performed using a magnetic bead-based extraction method. Theassay method used a combination of a PCR-based pre-amplification step,followed by an isothermal amplification and detection step. The highsensitivity of the assay was driven in part by a highly efficientautomated on-board sample extraction process performed by the automatedassay device. The primers used in the nucleic acid amplification Zikaassay were designed from a consensus of a multi-sequence alignment ofall Zika strains deposited in GenBank. The selected gene target was a100-base pair region within the highly conserved polyprotein gene.

As shown in FIG. 23B, Applicant presents results for analyticalsensitivity, specificity, and inclusivity to show the robustness of theplatform. Additionally, a clinical study was performed to demonstrateconcordance with reference methods.

As shown in FIG. 24 the Zika assay sensitivity is shown here using aZika strain from the Centers for Disease Control (CDC) that is of Asianlineage from the recent Zika outbreak. The LoD was determined by testingZika virus across a range of concentrations in serum, from 0 to 1920copies per mL. The LoD was determined to be 480 copies/mL and wasverified by testing 20 additional replicates. For reference this istwice as sensitive as the published LoD for the CDC Zika test.

As shown in FIG. 25, Applicant tested a panel of organisms that aregenetically or clinically similar to Zika, at very high concentrations,both in the absence and presence of the Zika virus, in order to confirmthe analytical specificity of the assay. As shown in the middle columns,there was no cross reactivity for any of the organisms tested. Theseorganisms did not cause any significant interference with the detectionof Zika virus, as shown in the columns to the right.

As shown in FIG. 26, there was no cross-reactivity or interferencedetected for any of the common potentially interfering substances, aslisted in the Table shown in FIG. 6.

Inclusivity data is shown in FIG. 27A, illustrating results from the NAAZika test and the CDC assay. As shown in FIG. 27A, the NAA Zika test wasable to detect these two additional Zika virus strains (of Africanlineage) while the CDC test did not.

The assays carried out using the methods and devices disclosed hereinshowed no significant carry-over between runs of testing on the samedevice. In these carryover studies, samples were tested with very highconcentrations of Zika virus and then run a using negative controlsample. As shown in FIG. 27B, no false positives were detected for anyof the negative controls, demonstrating no carry-over or crosscontamination between runs. This illustrates an advantage of thesingle-use cartridge format disclosed herein, in which a cartridge withcompletely sealed consumables is provided to the automated sampleanalysis device, and in which the sample, which is also provided in thecartridge, does not come in direct contact with the instrument but isinstead provided on, and carried by, the cartridge.

As shown in FIG. 28, samples were collected from 181 subjects, fromSouth America and the U.S., in order to evaluate clinical performance ofthe assays. 78 of the subjects were from the US—both healthy andfebrile, and 103 were from the Dominican Republic and Colombia andpresented with Zika symptoms. In order to ensure there were enoughpositive samples to compute percent agreements, the 39 naturallypositive samples were supplemented with 33 additional samples to whichZika virus was added. To calculate percent agreement, the NAA Zika assaywas compared to the CDC RT-PCR assay and also to the altona kit, whichhas received emergency use authorization (EUA).

FIG. 29 provides a comparison between the NAA Zika Assay and the CDCRT-PCR, with confirmation by the altona assay for both negative andpositive percent agreement along with the 95% confidence interval. TheNAA Zika assay shows a high level of concordance with the referencemethods. These results demonstrate that the automated sample analysisdevices disclosed herein can automatically perform molecular testingwith fully integrated assay and results processing, comparable tomethods that require highly trained personnel.

FIG. 30 provides an overview of some of the criteria of a clinical studyperformed using the NAA Zika Assay disclosed herein on capillary bloodsamples. Capillary samples were prospectively collected from healthy orsymptomatic subjects in the US or Dominican Republic, respectively, andshipped in small containers (Nanotainer™) to the United States foranalysis on the automated sample analysis devices (“minilabs”) asdisclosed herein. Capillary whole blood samples were tested on 20minilabs while venous serum and urine samples were tested using the CDCor Altona methods.

As shown in FIG. 31, the NAA Zika Assay using capillary whole bloodsamples on the miniLab showed a high level of concordance with thecomparator methods. There was only a single sample with added Zika virusthat was detected as negative by CDC but positive by Altona that wasdetected by the miniLab NAA Zika test as negative. The NAA Zika Assayperformed using the miniLab is believed to be the only Zika test thatcan use capillary blood.

While preferred embodiments of the present invention have been shown anddescribed herein, it will be obvious to those skilled in the art thatsuch embodiments are provided by way of example only. Numerousvariations, changes, and substitutions will now occur to those skilledin the art without departing from the invention. It should be understoodthat various alternatives to the embodiments of the invention describedherein may be employed in practicing the invention. For example, afeature of one embodiment may be combined with a feature of anotherembodiment, whether such combination is described herein or not. Itshould also be understood that while the invention provided herein hasbeen described herein using a limited number of terms and phrases forpurposes of expediency, the invention could also be described usingother terms and phrases not provided herein which also accuratelydescribe the invention.

Additionally, although some embodiments herein may describe the initialthermal cycling as a “PCR” process, many embodiments herein may performonly a thermal cycling style processing and not any type of detectionduring the initial “PCR” process. In embodiments, it should beunderstood that other processes that provide an increased number of copynumbers may be used for the initial sample enrichment. The term“initial” as used in the examples herein does not necessarily imply thatit is the first step, but merely that it occurs before one or morefollow-up detection step(s). Some embodiments may view this as apre-amplification step. Some embodiments may view this as a sampleenrichment step.

In embodiments, it should also be understood that the initial thermalcycling process may be performed on a bulk portion and/or common portionof the sample with a plurality of different binder types therein (ebola,malaria, etc. . . . ) for a plurality of different loci, whereinpost-thermal cycling, the process may be processed for more specificdetection such as but not limited to DNA amplification or otherdetection processing currently known or may be developed in the future.In such embodiments where there is bulk processing of sample with aplurality of different binders, it should be understood that detectionin the initial stage, although not specifically excluded, such detectionis generally not done due the variety of different binders in the samplethat may or may not yield actionable data. In embodiments, the hybridprocess can be configured to detect many targets from a single commonsample that is enriched, wherein the targets may be at least 5 or more.In embodiments, the process may detect many targets from a singlesample, wherein the targets may be at least 7 or more. In embodiments,the process may detect many targets from a single sample, wherein thetargets may be at least 10 or more. In embodiments, the process maydetect many targets from a single sample, wherein the targets may be atleast 20 or more.

In embodiments, the hybrid process herein may improve sensitivity of theisothermal process, at least in part due to the increase in copy numbersfrom the initial thermal cycling, but also provides better specificitythan PCR specificity, in part because of the use of at least twodifferent primers (for example, primer in thermal cycling process andprimer in the isothermal process). In embodiments, the initial processmay be coarser for the thermal cycling step for enriching for thetarget(s) and not necessarily for detection during the initialprocessing. In embodiments, the initial processing may createnon-specific product (along with creating more copies of the targetmaterial) and the processing of the sample in subsequent step providesat least a second layer of detection that is more specific for thedesired target(s) but having the benefit of more copies to detect due tothe enrichment from the initial step (even if creating some non-specificproduct in the process). In embodiments, the secondary or other laterdetection process of the hybrid process may be viewed as an end pointdetection that is sequence specific. In embodiments, the hybrid processmay be better than either a PCR process or isothermal processindividually in terms of sensitivity and specificity

In embodiments, some may use parallel track processing wherein at leastone portion of the initial sample is processed along one track using thehybrid process and at least another portion is processed on at least oneother track such as but not limited to another PCR process or anisothermal detection process. Because it may be the case that it isunknown if the sample has sufficient copy numbers of a target in thesample, some situations may occur where pre-amplification is not neededfor detection to occur in one of the non-hybrid processing tracks,particularly if copy numbers are sufficient without sample enrichment.If one track returns a signal sooner, the process may be stopped earlierif a sufficient response is received on one track that reduces the needto continue detection along one of the other parallel tracks. Inembodiments, a sample processing device may include at least one thermalcycler and at least one non-cycling heater. Optionally, some embodimentsmay have multiple thermal cyclers wherein at one can be controlled notto cycle. In embodiments, some embodiments may have a thermal cyclerwith fewer wells, chambers, or vessels for thermal cycling that thesubsequent detection process, but optionally, each may be configured tohold larger volumes than the wells of the follow-on detection method.Thus, one embodiment may have one or two wells, chambers, or vessels forthermal cycling and at least 10 or more wells, chambers, or vessels forthe follow-on detection, where each well, chamber, or vessel may be morespecific for certain loci. In such an embodiment, a division of thesample into smaller aliquots may occur after the initial thermal cyclingstep that enriches the sample. In one embodiments, a control sample mayalso be thermal cycled for control purposes.

It should be understood that as used in the description herein andthroughout the claims that follow, the meaning of “a,” “an,” and “the”includes plural reference unless the context clearly dictates otherwise.For example, a reference to “an assay” may refer to a single assay ormultiple assays. Also, as used in the description herein and throughoutthe claims that follow, the meaning of “in” includes “in” and “on”unless the context clearly dictates otherwise. The appended claims arenot to be interpreted as including means-plus-function limitations,unless such a limitation is explicitly recited in a given claim usingthe phrase “means for.” As used in the description herein and throughthe claims that follow, a first object described as containing “at leasta portion” of a second object may contain the full amount of/thecomplete second object.

As used in the description herein and throughout the claims that follow,the terms “comprise”, “include”, and “contain” and related tenses areinclusive and open-ended, and do not exclude additional, unrecitedelements or method steps. Also, the presence of broadening words andphrases such as “one or more,” “at least,” “but not limited to” or otherlike phrases in some instances shall not be read to mean that thenarrower case is intended or required in instances where such broadeningphrases may be absent. Finally, as used in the description herein andthroughout the claims that follow, the meaning of “or” includes both theconjunctive and disjunctive unless the context expressly dictatesotherwise. Thus, the term “or” includes “and/or” unless the contextexpressly dictates otherwise.

This document contains material subject to copyright protection. Thecopyright owner (Applicant herein) has no objection to facsimilereproduction by anyone of the patent documents or the patent disclosure,as they appear in the US Patent and Trademark Office patent file orrecords, but otherwise reserves all copyright rights whatsoever. Thefollowing notice shall apply: Copyright 2013-16 Thermos, Inc.

1. A method for amplifying a target nucleic acid sequence in a sample,comprising: first amplifying the number of copies of one or more targetnucleic acid sequences in the sample by a first nucleic acidamplification method; and next further amplifying the number of copiesof said one or more target nucleic acid sequences in the sample, or analiquot thereof, by a second nucleic amplification method.
 2. The methodof claim 1, wherein said first nucleic acid amplification methodcomprises a thermocycling nucleic acid amplification method.
 3. Themethod of claim 1, wherein said second nucleic acid amplification methodcomprises an isothermal nucleic amplification method.
 4. The method ofclaim 1, wherein said first nucleic acid amplification method comprisesa thermocycling nucleic acid amplification method, and said secondnucleic acid amplification method comprises an isothermal nucleicamplification method.
 5. The method of claim 1, wherein said firstnucleic acid amplification method comprises a polymerase chain reaction(PCR) nucleic acid amplification method.
 6. The method of claim 1,wherein said second nucleic acid amplification method comprises anisothermal nucleic amplification.
 7. The method of claim 5, wherein thenucleic acid amplified by the PCR amplification method comprises DNA. 8.The method of claim 5, wherein the nucleic acid amplified by the PCRamplification method comprises RNA.
 9. The method of claim 1, whereinprimers used in the amplification methods are directed to a singletarget nucleic acid sequence, and its complement.
 10. The method ofclaim 1, wherein primers used in the amplification methods are directedto a plurality of target nucleic acid sequences, and complementsthereof.
 11. A method for detecting a first genetic element and a secondgenetic element on a common nucleic acid molecule, the methodcomprising: performing a first nucleic acid amplification reaction usinga first primer and a second primer, wherein both the first primer andthe second primer are phosphorylated on the 5′ end of the primer,wherein the first primer is complementary to the first genetic element,wherein the second primer is complementary to the second geneticelement, and wherein a first reaction product is formed, wherein thefirst reaction product contains at least a portion of the first geneticelement and at least a portion of the second genetic element, whereinthe least a portion of the first genetic element and at least a portionof the second genetic element are separated from each other in the firstreaction product by X number of nucleotides; incubating the firstreaction product with a ligase enzyme, to form at least a first ligationproduct containing the first reaction product, wherein within the firstligation product a copy of the at least a portion of the first geneticelement and a copy of the at least a portion of the second geneticelement are separated from each other by less than X number ofnucleotides; performing a second nucleic acid amplification reactionusing a third primer and a fourth primer, wherein the third primer iscomplementary to the first genetic element, and wherein the fourthprimer is complementary to the second genetic element, wherein a secondreaction product is formed; detecting the second reaction product; andusing a cut-off time to end said detecting of the second reactionproduct.
 12. A method for amplifying a polynucleotide template, themethod comprising: A) generating multiple copies of a polynucleotidetemplate in a polymerase chain reaction (PCR) amplification reactionmixture, wherein the sample is derived from capillary whole bloodwherein the PCR amplification reaction mixture comprises a first PCRamplification reaction primer and a second PCR amplification reactionprimer, wherein in the PCR amplification reaction mixture, the first PCRamplification reaction primer anneals to the polynucleotide template andthe second PCR amplification reaction primer anneals to a polynucleotidewhich is complementary to the polynucleotide template, and wherein inthe PCR amplification reaction mixture, multiple copies of a PCRamplification reaction product are formed, wherein the PCR amplificationreaction product is a double-stranded nucleic acid molecule comprising afirst strand and a second strand, and wherein a first strand of the PCRamplification reaction product is a copy of the polynucleotide template;B) incubating copies of the polynucleotide template in anon-thermocycling reaction mixture comprising a non-thermocyclingreaction first primer and a non-thermocycling reaction second primer,wherein: the polynucleotide template comprises a first portion, a secondportion and a third portion, wherein the third portion is situated inthe polynucleotide template between the first portion and the secondportion; the first primer comprises a first region and a second region,wherein the second region of the first primer is complementary to thefirst portion of the polynucleotide template; and the second primercomprises a first region and a second region, wherein the second regionof the second primer is complementary to a sequence in the PCRamplification reaction product second strand which is complementary tothe second portion of the polynucleotide template, the first region ofthe second primer is complementary to the first region of the firstprimer, and the first region of the second primer is complementary tothe third portion of the polynucleotide template.
 13. The method ofclaim 12, wherein the first portion and second portion of thepolynucleotide template are each between 6 and 30 nucleotides in length.14. The method of claim 12, wherein the third portion of thepolynucleotide template is between 4 and 14 nucleotides in length. 15.The method of claim 12, wherein the number of copies of thepolynucleotide template in the non-thermocycling reaction mixture isincreased at least 10-fold within 60 minutes of initiation of themethod.
 16. The method of claim 12, wherein a concatemer strandcomprising at least three copies of the polynucleotide template isgenerated during the incubation of the non-thermocycling reactionmixture.
 17. A vessel, comprising therein any one or more components ofa reaction mixture provided in claim
 11. 18. A kit, comprising thereinany one or more components of a reaction mixture provided in claim 11.